Updated version January 2010
EUROPEAN UNION
Committee of the Regions
DECLARATION CONCERNING GROUNDS FOR EXCLUSION AND ABSENCE OF CONFLICT OF INTEREST
The undersigned (economic operator): ………………………………………………………………….
Trading name of company or organisation: ……………………………..……………...……………….
Official address in full: .........................................................................................................................…
Official legal form1: ..................................................................................................................................
Statutory registration number2: …………………………………..……………………………..………
VAT number: ……………………………………………………...…………………………………….
Name of person signing this form (designated individual legally authorised to represent the tenderer
or candidate in dealings with third parties and acting on behalf of the above-mentioned company or
organisation):
Hereby declares that the above-mentioned company or organisation:
Exclusion from participation in the tender procedure
a) is not bankrupt or being wound up, is not having its affairs administered by the courts, has not
entered into an arrangement with creditors, has not suspended business activities, is not in any
analogous situation arising from proceedings of this nature, or a similar procedure under national
laws or regulations;
b) has not been convicted of an offence concerning professional conduct by a judgment which has
the force of res judicata;
c) has not been guilty of grave professional misconduct proven by any means which the contracting
authorities can justify;
d) has fulfilled its obligations relating to the payment of social security contributions or the payment
of taxes in accordance with the legal provisions of the country in which it is established, the
1
2
Unless the Contractor is a natural person or a body governed by public law.
Delete if the Contractor is a body governed by public law. For natural persons, indicate the number of their identity card or,
failing that, of their passport or equivalent.
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-2country of the contracting authority, and those of the country where the contract is to be
performed;
e) has not been the subject of a judgment which has the force of res judicata for fraud, corruption,
involvement in a criminal organisation or any other illegal activity detrimental to the financial
interests of the European Union;
f)
is not currently subject to an administrative penalty, referred to in Article 96(1) of Council
Regulation (EC, Euratom) No 1605/2002 of 25 June 2002 (OJ L 25, 30.1.2003) on the Financial
Regulation applicable to the general budget of the European Communities, as amended by
Council Regulation (EC, Euratom) No 1995/2006 of 13 December 2006 (OJ L 390, 30.12.2006)
Exclusion from the award of a contract
g) does not have any conflict of interest in connection with the contract; a conflict of interest may
arise in particular as a result of economic interests, political or national affinities, family or
emotional ties, or any other relevant connection or shared interest;
will, if need be, inform the contracting authority, without delay, of any situation constituting a
conflict of interest or which could give rise to a conflict of interest;
has not made and will not make any offer of any type whatsoever from which an advantage can
be derived under the contract;
has not granted, sought, attempted to obtain or accepted and will not grant, seek, attempt to
obtain, or accept any advantage, financial or in kind, to or from any party whatsoever, constituting
an illegal or corrupt practice, either directly or indirectly, as an incentive or reward relating to the
award of the contract;
h) is not guilty of misrepresentation when furnishing information required by the contracting
authority in order to take part in a procurement procedure, or of failing to furnish such
information.
i)
is not subject to one of the criteria for exclusion from the procurement procedure outlined in
points a) to f) above
NOTE: By returning this form duly signed, the undersigned accepts that, if awarded the contract, it
will be necessary to [provide at the Committee's request3] [to provide4], within the deadline stipulated
3
This option relates to contracts of less than EUR 125 000 for public supply contracts and public service contracts and of less than
EUR 4 845 000 for works contracts.
4
This option relates to contracts equal to or greater than EUR 125 000 for public supply contracts and public service contracts and
equal to or greater than EUR 4 845 000 for works contracts.
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-3in writing by the contracting authority and before the contract is signed, the following supporting
documents confirming its declaration:
For situations described in (a), (b) and (e), a recent extract from the judicial record is required
or, failing that, a recent equivalent document issued by a judicial or administrative authority
in the country of origin or provenance showing that those requirements are satisfied. Where
the tenderer is a legal person and the national legislation of the country in which it is
established does not allow the provision of such documents for legal persons, the documents
should be provided for natural persons, such as directors or any person with powers of
representation, decision making or control in relation to the tenderer.
For the situation described in (c), any document (e.g. an appropriate statement or certificate
issued by a judicial or administrative authority in the country of origin or provenance)
showing that the contractor has not been found guilty of grave professional misconduct or
declared in serious breach of its contractual obligations in relation to another procurement
procedure or grant award procedure financed by the Union budget;
For the situation described in (d) above, recent certificates or letters issued by the competent
authorities of the State concerned are required. These documents must provide evidence
covering all taxes and social security contributions for which the tenderer is liable, including
for example, VAT, income tax (natural persons only), company tax (legal persons only) and
social security contributions;
For any of the situations described in (a), (b), (d) or (e), where any document described in the
two paragraphs above is not issued in the country concerned, it may be replaced by a
statement on oath, or failing that, a solemn declaration made by the interested party before a
judicial or administrative authority, a notary or a qualified professional body in his country of
origin or provenance.
In the case of a consortium of contractors, the signed declaration (as well as the supporting
documents and information required if the contract is granted) must be provided individually
by each member of the group.
By signing this form, the undersigned acknowledges awareness of the administrative and financial
penalties described under Articles 133 and 134 b of the Implementing Rules (Commission Regulation
(EC, Euratom) No 2342/2002 of 23 December 2002), which may be applied if any of the declarations
or information provided prove to be false.
Surname, Name
Date
Signature
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