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EXHIBIT E – DARFUR CONTRACTING ACT <br />SAMPLE FORM <br />Public Contract Code Sections 10475 -10481 applies to any company that currently or within the <br />previous three years has had business activities or other operations outside of the United States. <br />For such a company to bid on or submit a proposal for a State of California contract, the company <br />must certify that it is either a) not a scrutinized company; orb) a scrutinized company that has been <br />granted permission by the Department of General Services to submit a proposal. <br />If your company has not, within the previous three years, had any business activities or other <br />operations outside of the United States, you do not need to complete this form. <br />OPTION #1 - CERTIFICATION <br />If your company, within the previous three years, has had business activities or other operations <br />outside of the United States, in order to be eligible to submit a bid or proposal, please insert your <br />company name and Federal ID Number and complete the certification below. <br />I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that a) the prospective <br />proposer/bidder named below is not a scrutinized company per Public Contract Code 10476; and b) I <br />am duly authorized to legally bind the prospective proposer/bidder named below. This certification is <br />made under the laws of the State of California. <br />Company/Vendor Name (Printed) <br />{grantee_name} <br />Federal ID Number <br />{fed_id} <br />By (Authorized Signature) <br />{agy_sign_name} <br />Date <br />{agy_sign_dt} <br />Printed Name and Title of Person Signing <br />{agy_sign_name}, {agy_sign_dsg} <br />OPTION #2 - WRITTEN PERMISSION FROM DGS <br />Pursuant to Public Contract Code Section 10477(b), the Director of the Department of General <br />Services may permit a scrutinized company, on a case-by-case basis, to bid on or submit a proposal <br />for a contract with a state agency for goods or services, if it is in the best interests of the state. If you <br />are a scrutinized company that has obtained written permission from the DGS to submit a bid or <br />proposal, complete the information below. <br />We are a scrutinized company as defined in Public Contract Code section 10476, but we have <br />received written permission from the Department of General Services to submit a bid or proposal <br />pursuant to Public Contract Code section 10477(b). A copy of the written permission from DGS is <br />included with our bid or proposal. <br />Company/Vendor Name (Printed) <br />{grantee_name} <br />Federal ID Number <br />{fed_id} <br />By (Authorized Signature) <br />{agy_sign_name} <br />Date <br />{agy_sign_dt} <br />Printed Name and Title of Person Signing <br />{agy_sign_name}, {agy_sign_dsg} <br />Date: 09/20/2023 Contract # C23SO609, City of San Leandro Marina, Surrendered and Abandoned Vessel <br />Exchange (SAVE) Fiscal Year 2023/2024 <br />__________________________________________________________________________ <br />Page: 29 of 4343Date: 09/20/2023 Contract # C23SO609, City of San Leandro Marina, Surrendered and Abandoned Vessel <br />Exchange (SAVE) Fiscal Year 2023/2024 <br />__________________________________________________________________________ <br />Page: 29 of 4343