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Local .Assistance Procedures Manual <br />PUBLIC CONTRACT CODE <br />PUBLIC CONTRACT CODE SECTION 10285.1 STATEMENT <br />Exhibit 12-H <br />Sample Bid <br />In conformance with Public Contract Code Section 10285.1 (Chapter 376, Stats. 1985), the bidder hereby declares <br />under penalty of perjury under the laws of the State of California that the bidder has _ , has not been convicted <br />within the preceding three years of any offenses referred to in that section, including any charge of fraud, bribery, collusion, <br />conspiracy, or any other act in violation of any state or Federal antitrust law in connection with the bidding upon, award of, <br />or performance of, any public works contract, as defined in Public Contract Code Section 1101, with any public entity, as <br />defined in Public Contract Code Section 1100, including the Regents of the University of California or the Trustees of the <br />California State University. The term "bidder" is understood to include any partner, member, officer, director, responsible <br />managing officer, or responsible managing employee thereof, as referred to in Section 10285.1. <br />Note: The bidder must place a checkmark after "has" or "has not" in one of the blank spaces provided, The above <br />Statement is part of the Proposal. Signing this Proposal on the signature portion thereof shall also constitute <br />signature of this Statement. Bidders are cautioned that making a false certification may subject the certifier to <br />criminal prosecution. <br />PUBLIC CONTRACT CODE SECTION 10162 QUESTIONNAIRE <br />In conformance with Public Contract Code Section 10162, the Bidder shall complete, under penalty of perjury, the following <br />questionnaire: <br />Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the bidder, ever been <br />disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project <br />because of a violation of law or a safety regulation? <br />Yes _ No <br />If the answer is yes, explain the circumstances in the following space. <br />NI ft <br />LPP 18-01 <br />20E-37 <br />Page 7 of 22 <br />January 2019 <br />