Standard

Procurement
Documents
 Self-Certification
Form – Bidding Stage

1st Edition

December 2020

This form should be added as an additional bidding form when national bidding
documents are used. The use of this self-certification form is mandatory for all
procurements carried out in IFAD-financed or managed projects and they are
included in IFAD’s standard bidding documents.
 Form [insert number/reference] : Self-Certification Form

Preamble:

In accordance with the IFAD Policy on Preventing Fraud and Corruption in its Activities and
Operations, the Fund may investigate and, when applicable, sanction entities and individuals,
including by debarring them, either indefinitely or for a stated period of time, to participate in
any IFAD-financed or IFAD-managed activity or operation. This obligation applies to but is not
limited to past sanctions and/or debarments. A debarment includes, inter alia, ineligibility to:
(i) be awarded or otherwise benefit from any IFAD-financed contract, financially or in any
other manner; (ii) be a sub-contractor, consultant, manufacturer, supplier, sub-supplier, agent
or service provider of an otherwise eligible firm being awarded an IFAD-financed contract;
and (iii) receive the proceeds of any loan or grant provided by the Fund. The Fund may also
unilaterally recognize eligible debarments by any of the International Financial Institutions
signatories to the Agreement for Mutual Enforcement of Debarment Decisions. 1

Self-Certification Form

This self-certification form is to be completed by the bidder. The bidder shall submit the
completed form together with the bid/proposal to [insert name of procuring entity]. Instructions
for completing this form are provided below.

Full legal name of bidder:

Full legal name of bidders's legal
representative and position:
Procurement title:
Procurement reference:
Date:

I hereby certify that I am the authorized representative of [name of the bidder], as well as that
the information provided above is true and accurate in all material respects and understand
that any material misstatement, misrepresentation or failure to provide the information
requested in this certification may result in sanctions and remedies, including the permanent
ineligibility to participate in IFAD-financed and/or IFAD-managed activities and operations, in
accordance with the IFAD Procurement Guidelines, the IFAD Procurement Handbook and
other applicable IFAD policies and procedures, including the IFAD Policy on Preventing
Fraud and Corruption in its Activities and Operations (accessible at
www.ifad.org/anticorruption_policy) and the IFAD Policy on Preventing and Responding to
1
The Cross-Debarment Agreement was entered into by the World Bank Group, the Inter-American Development Bank, the African
Development Bank, the Asian Development Bank and the European Bank for Reconstruction and Development, additional information
may be located at: http://crossdebarment.org/.

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Sexual Harassment, Sexual Exploitation and Abuse (accessible at
https://www.ifad.org/en/document-detail/asset/40738506).

Authorized Signature: ____________________________ Date: ______________

Printed Name of Signatory:____________________________________________

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  The bidder certifies that itself, its proprietor(s), agents, sub-consultants, sub-contractors,
consortium and joint venture partners have NOT engaged in fraudulent, corrupt, collusive,
coercive or obstructive practices in connection with the present procurement process.

 The bidder declares that the following criminal convictions, administrative sanctions
(including debarments under the Agreement for Mutual Enforcement of Debarment
Decisions or the "Cross-Debarment Agreement")2 and/or temporary suspensions have
been imposed on the bidder and/or any of its directors, partners, proprietors, key
personnel, agents, sub-consultants, sub-contractors, consortium and joint venture
partners:

Nature of the Imposed by Name of party Grounds for the Date and
measure (i.e., convicted, measure (i.e., time
criminal conviction, sanctioned or fraud in (duration) of
administrative suspended (and procurement or measure
sanction or relationship to corruption in
temporary bidder) contract
suspension) execution)

If no criminal convictions, administrative sanctions or temporary suspensions have been

imposed, indicate “none”.

 The bidder certifies that itself, including its director(s), partner(s), proprietor(s), key
personnel, agents, sub-consultants, sub-contractors, consortium and joint venture
partners have NOT engaged in acts of sexual harassment, sexual exploitation and abuse
in connection with the present procurement process and this contract.

 The bidder certifies that itself, including its director(s), partner(s), proprietor(s), key
personnel, agents, sub-consultants, sub-contractors, consortium and joint venture
partners are NOT subject to a criminal conviction, administrative sanctions and/or
temporary suspensions for engaging in acts of sexual harassment, sexual exploitation and
abuse.

 The bidder certifies that itself, its proprietor(s), agents, sub-consultants, sub-contractors,
consortium and joint venture partners have NO actual, potential or reasonably perceived
conflicts of interest and specifically that they:

 Do not have any actual or potential, and do not reasonably appear to have, at least
one controlling partner in common with one or more other parties in the bidding

2
The Cross-Debarment Agreement was entered into by the World Bank Group, the Inter-American Development Bank, the
African Development Bank, the Asian Development Bank and the European Bank for Reconstruction and Development,
additional information may be located at: http://crossdebarment.org/.

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 process or the execution of the contract;

 Do not have any actual or potential, and do not reasonably appear to have, the
same legal representative as another bidder for purposes of this bid or execution of
the contract;

 Do not have any actual or potential, and do not reasonably appear to have, a
relationship, directly or through common third parties, that puts them in a position
to have access to undue or undisclosed information about or influence over the bid
process and the execution of the contract, or influence the decisions of the
procuring entity regarding the selection process for this procurement or during the
execution of the contract;

 Do not participate and do not potentially or reasonably appear to participate in

more than one bid/proposal in this process; and

 Do not have any actual or potential, and do not reasonably appear to have, a
business or family relationship with, a member of the procuring entity’s board of
directors or its personnel , the Fund or its personnel, or any other individual that
was, has been or might reasonably be directly or indirectly involved in any part of
(i) the preparation of the bidding document, (ii) the selection process for this
procurement, or (iii) execution of the contract, unless the actual, potential or
reasonably conflict stemming from this relationship has been explicitly authorized
by the Fund in writing.

 [To be completed only if the previous boxes were not checked]

The bidder declares the following actual, potential or reasonably perceived conflicts
of interest, that may affect, or might reasonably be perceived by others to affect,
impartiality in any matter relevant to the procurement process, including the
selection process and the execution of the contract, with the understanding and
acceptance that any action upon this disclosure shall be entirely under the Fund’s
discretion:

[provide detailed description of any actual, potential or reasonably perceived

conflicts of interest including their nature and the personnel, proprietor(s), agents,
sub-consultants, sub-contractors, consortium or joint venture partners affected.]

 The bidder certifies that NO gratuities, fees, commissions, gifts or anything else of value
have been paid or exchanged or are to be paid or exchanged with respect to the present
bidding process.

OR

 [To be completed only if previous box was not checked]

The bidder declares that the following gratuities, fees, commissions, gifts or anything else
of value have been exchanged, paid or are to be exchanged or paid with respect to the
present bidding process:

- [Name of Recipient/Address/Date/Reason/Amount]
- [Name of Recipient/Address/Date/Reason/Amount]

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 Instructions for completing the self-certification form

The World Bank listing of ineligible firms and individuals is a searchable database that returns
a positive or negative search results page upon submission of a name to be searched, in
order to document the eligibility.

The bidder should print out, date, and attach the results page(s) to the self-certification
form.

If (a) record(s) has/have been found – i.e. the results page(s) shows one or more individuals
or entities, including the bidder itself are ineligible for contracts of the World Bank on the
grounds of “cross-debarment”, the bidder should provide a detailed account of these
sanctions and their duration as applicable or notify the procuring entity and in case the bidder
believes the finding is a “false positive”.