ࡱ> VYSTU38Fbjbj&&QQDhDh  M W 8\[<V-Z ! !,,,,,,,$/f2,i%! ^%!%!,cc-%%%%!cc8,%%!,%%r*Tq+y蝬 "#+m,&-0V-?+22)"2q+q+82+%%!%!%!,,$%!%!%!V-%!%!%!%!2%!%!%!%!%!%!%!%!%!c : ZaBcznik nr 1a do SWZ Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (imi, nazwisko, stanowisko/podstawa do reprezentacji) O[wiadczenie wykonawcy skBadane na podstawie art. 125 ust. 1 ustawy z dnia 11 wrze[nia 2019 r. Prawo zamwieD publicznych (dalej jako: ustawa Pzp), DOTYCZCE PRZESAANEK WYKLUCZENIA Z POSTPOWANIA Na potrzeby postpowania o udzielenie zamwienia publicznego pn. Dostawa sprztu komputerowego w ramach projektu  Cyfrowa Gmina ,  Wsparcie dzieci z rodzin pegeerowskich w rozwoju cyfrowym  Granty PPGR oraz konkursu  Rosnca odporno[ , prowadzonego przez Gmin Olszwka, o[wiadczam, co nastpuje: A. OZWIADCZENIE DOTYCZCE WYKONAWCY: (wypeBni wBa[ciwy punkt/skre[li niewBa[ciwy) O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 108 ustawy Pzp. & & & & & .& & . (miejscowo[), dnia & & & & .& & . r. & & & & & & & & & & & & & & & & (podpis) O[wiadczam, |e zachodz w stosunku do mnie podstawy wykluczenia z postpowania na podstawie art. & & & & & & & & & ..ustawy Pzp (poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych w art. 108 ust. 1 pkt 1,2 i 5). Jednocze[nie o[wiadczam, |e w zwizku z ww. okoliczno[ci, na podstawie art. 110 ust. 2 ustawy Pzp podjBem nastpujce [rodki naprawcze: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & . & & & & & .& & . (miejscowo[), dnia & & & & & & & . r. & & & & & & & & & & & & & & & & (podpis) O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 7 ust. 1 ustawy z dnia 13 kwietnia 2022 r. o szczeglnych rozwizaniach w zakresie przeciwdziaBania wspieraniu agresji na Ukrain oraz sBu|cych ochronie bezpieczeDstwa narodowego (Dz. U. z 2022 r., poz. 835). & & & & & .& & . (miejscowo[), dnia & & & & & & & . r. & & & & & & & & & & & & & & & & (podpis) B. OZWIADCZENIE DOTYCZCE PODMIOTU, NA KTREGO ZASOBY POWOAUJE SI WYKONAWCA : (je[li dotyczy) (je[li nie dotyczy przekre[li) O[wiadczam, |e w stosunku do nastpujcego/ych podmiotu/tw, na ktrego/ych zasoby powoBujsiwniniejszympostpowaniu,tj.:& & & & & & & & & & & & & & & & & & & & & & & (poda peBn nazw/firm, adres, a tak|e w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG) nie zachodz podstawy wykluczenia z postpowania o udzielenie zamwienia wskazane w pkt A ppkt 1 i 3. & & & & & .& & . (miejscowo[), dnia & & & & & & & . r. & & & & & & & & & & & & & & & & (podpis) C. OZWIADCZENIE DOTYCZCE PODWYKONAWCY NIEBDCEGO PODMIOTEM, NA KTREGO ZASOBY POWOAUJE SI WYKONAWCA: (je[li dotyczy) (je[li nie dotyczy przekre[li) O[wiadczam, |e w stosunku do nastpujcego/ych podmiotu/tw, bdcego/ych podwykonawc/ami: & & & & & & & & & & & & & & & & & & & & & & & & & & ..& .& &  .02HJln  N P ~  6 8 : < h j l j l  F L N ୻୻໻~hVhd]5CJaJhVhd]5CJPJaJhVhd]5>* *hVhd]5>*hVhd]6CJPJaJhVhd]6CJaJhVhd]CJaJhVhd]5>*CJaJ hVhd]hVhE5CJaJhVhd]5CJaJ.02Jn P 8 : < l l , dh-DM $9dh`9a$ $dhxa$$dha$ $dhxa$dh$dha$ $ p#dha$N *,^v~(*,ߵǀun\#hVhd]6CJOJQJ^JaJ hVh%hVh%CJaJhVhd]6CJaJhVhd]CJaJhVhd]OJQJ^J hVhd]CJOJQJ^JaJ#hVhd]6CJOJQJ^JaJhVhd]6CJaJhVhd]5CJaJ hVhd]hVhd]CJaJhVhE5CJPJaJ *,.02$h^ha$$ & F^`a$gd4_%$dh^a$gd$ dh^ `a$$dha$%$ & Fd^`a$gd4_ %$dha$,.02^h ^hL  `bfrtvxü˰ץ׼˒hVhgevCJaJhVh4_6CJaJ hVh1w+hVh1w+CJaJhVhd]6CJaJ hVhd]hVCJaJhVhd]6CJaJhVhd]CJaJhVhd]CJaJ#hVh1w+6CJOJQJ^JaJ1  btv $h^ha$gdgev$a$gd$*$1$3$5$7$8$H$]^a$gd1w+!$ & F*$1$3$5$7$8$H$]^`a$gd4_$ dh^ `a$$dha$$h^ha$  `fntx ӵӠthhVhgev6CJaJhVhgev6CJaJhVhgevCJaJ(hVh1w+>*B*PJmHphsHtH(hVh>*B*PJmHphsHtH:jhVhu0J,B*CJPJUaJmHphsHtH-hVhB*CJPJaJmHphsHtHhVhCJaJhVhySkCJaJ&hjz|~ f~6bdf,.024ĽzncczzhVh'CJaJhVhd]6CJaJhVhd]CJaJhVhd]CJaJhVhd]56CJaJ hVhd]hVhd]5CJaJhVhd]6CJaJ hVh:hVh:6CJaJhVhgev6CJaJ hVhgevhVhgevCJaJ hVh1w+hVh1w+CJaJ&j|~02433$ dh^ `a$$dh-DM a$$dha$$ dh^ `a$gdgev $dha$gdgev4>Hdff22222222D3F3|3~33333333333344 4444ĶҝҒhVh'CJaJhVhd]CJaJUhVhd]5CJaJhVhd]56CJaJ hVhu hVhd]hVhd]CJaJhVhd]6CJaJhVhd]6CJaJhVhd]CJaJ8(poda peBn nazw/firm, adres, a tak|e w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG), nie zachodz podstawy wykluczenia z postpowania o udzielenie zamwienia wskazane w pkt A ppkt 1 i 3. & & & & & .& & . (miejscowo[), dnia & & & & & & & . r. & & & & & & & & & & & & & & & & (podpis) Dokument nale|y wypeBni i podpisa kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym. Zamawiajcy zaleca zapisanie dokumentu w formacie PDF.  Zgodnie z art. 7 ust. 1 ustawy z dnia 13 kwietnia 2022 r. o szczeglnych rozwizaniach w zakresie przeciwdziaBania wspieraniu agresji na Ukrain oraz sBu|cych ochronie bezpieczeDstwa narodowego (Dz. U. z 2022 r., poz. 835) z postepowania o udzielenie zamwienia publicznego lub konkursu prowadzonego na podstawie ustawy wyklucza si: wykonawc wymienionego w wykazach okre[lonych w rozporzdzeniu 756/2006 i rozporzdzeniu 269/2014 albo wpisanego na list na podstawie decyzji w sprawie wpisu na list rozstrzygajcej o zastosowaniu [rodka, o ktrym mowa w art. 1 pkt 3; wykonawc, ktrego beneficjentem rzeczywistym w rozumieniu ustawy z dnia 1 marca 2018 r. o przeciwdziaBaniu praniu pienidzy oraz finansowaniu terroryzmu (Dz. U. z 2022 r., poz. 593 i 655) jest osoba wymieniona w wykazach okre[lonych w rozporzdzeniu 765/2006 i rozporzdzeniu 269/2014 albo wpisana na list lub bdca takim beneficjentem rzeczywistym od dnia 24 lutego 2022 r., o ile zostaBa wpisana na list na podstawie decyzji w sprawie wpisu na list rozstrzygajcej o zastosowaniu [rodka, o ktrym mowa w art. 1 pkt. 3; wykonawc, ktrego jednostk dominujc w rozumieniu art. 3 ust. 1 pkt. 37 ustawy z dnia 29 wrze[nia 1994 r. o rachunkowo[ci (Dz. U. z 2021 r., poz. 217, 2105 i 2106) jest podmiot wymieniony w wykazach okre[lonych w rozporzdzeniu 765/2006 i rozporzdzeniu 269/2014 albo wpisany na list lub bdcy tak jednostk dominujc od dnia 24 lutego 2022 r., o ile zostaB wpisany na list na podstawie decyzji w sprawie wpisu na list rozstrzygajcej o zastosowaniu [rodka, o ktrym mowa w art. 1 pkt 3. Lista osb i podmiotw (lista), wobec ktrych s stosowane [rodki, o ktrych mowa powy|ej, jest prowadzona przez ministra wBa[ciwego do spraw wewntrznych i publikowana w Biuletynie Informacji Publicznej na stronie podmiotowej ministra wBa[ciwego do spraw wewntrznych.      Projekt  Cyfrowa gmina jest finansowany ze [rodkw Europejskiego Funduszu Rozwoju Regionalnego w ramach Programu Operacyjnego Polska Cyfrowa na lata 2014-2020.   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