ࡱ> be_`aK(/bjbj|8~8i~8i h0J0JWWWWWWWW8XD]X$Wr~XXLXXXZZZqqqqqqq$%xzhr]WZZZZZrWWXXHar[[[ZRWXWXq[Zq[[~ 9E$dX-f\}gZ"Vqwr0rW` C{ZC{$d$dC{Wf ZZ[ZZZZZrr[ZZZrZZZZC{ZZZZZZZZZ0Jc V:Numer sprawy IZP-IV.271.1.20.2023 ZaBcznik nr 6 do zapytania ofertowego Zamawiajcy: Gmina Gorzw Zlski ul. Wojska Polskiego 46-310 Gorzw Zlski Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & ... (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEiDG) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & .. (imi, nazwisko, stanowisko/podstawa do reprezentacji) O Z W I A D C Z E N I E DOTYCZCE PRZESAANEK WYKLUCZENIA Z POSTPOWANIA Na potrzeby postpowania o udzielenie zamwienia publicznego pn. ,,PeBnienie funkcji Inspektora Nadzoru inwestorskiego dla zadania pn.:  Przebudowa drg gminnych na terenie gminy Gorzw Zlski IZP-IV.271.1.20.2023   prowadzonego przez Gmin Gorzw Zlski 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 (tj. Dz. U. z dnia 15 kwietnia 2022 r. poz. 835), zwanej dalej  ustaw . Na podstawie art. 7 ust. 1 ustawy z postpowania wyklucza si: 1) Wykonawc oraz uczestnika konkursu wymienionego w wykazach okre[lonych w rozporzdzeniu 765/2006 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 ustawy; .48DFprtʼvhZLZ>h~/h9w5OJQJ^Jh~/hOJQJ\^Jh~/hOOJQJ\^Jh~/h~/OJQJ\^Jh~/hwGOJQJ\^Jh~/hmOJQJ\^Jh~/hO5OJQJ^Jh~/h tO5OJQJ^Jh~/h~aT5OJQJ^Jh~/hJz5OJQJ^Jh~/hwG5OJQJ^Jh~/hZ$5OJQJ^Jh~/hZ$OJQJ^Jh~/h(OJQJ^J 2 \ r t F x $dh(&d-DM Pa$gd^Adh1$]Agd /Adh1$]AgdN:Bdh1$]BgdN: dh1$gdN:(dhG$^(gdN: (dh^(gdN: dhgdN:    . 2 Z \ r ̾s`M:$h[ophEOJPJQJ^JnHtH$h[ophROJPJQJ^JnHtH$h[ophDOJPJQJ^JnHtH$h[oph9wOJPJQJ^JnHtH$h[oph7OJPJQJ^JnHtH-h[oph756>*OJPJQJ^JnHtHh[oph9w5OJQJ^Jh[ophZ$5OJQJ^Jh[ophZ$5>*OJQJ^J!h[ophZ$56>*OJQJ^J#h[oph9w5CJOJQJ^JaJ  t > D F H J L N P R T V X Z \ ^ ` b d f h j l ı띉lOlOlOlOlOlOlOlOlOl8h_]h^5B* CJOJPJQJ^JaJnHph `tH8h_]h9w5B* CJOJPJQJ^JaJnHph `tH'h[ophD6OJPJQJ^JnHtH'h[ophp6OJPJQJ^JnHtH$h[oph9wOJPJQJ^JnHtH$h[oph7OJPJQJ^JnHtH'h[oph7>*OJPJQJ^JnHtH'h[oph76OJPJQJ^JnHtHl n p r v x  X Z ^ L X Z t Ʃ||||iSSSS=======*h~/h~aT5OJPJQJ\^JnHtH*h~aTh~aT5OJPJQJ\^JnHtH$h[oph9wOJPJQJ^JnHtH$h[oph7OJPJQJ^JnHtH2hEh75>*CJOJPJQJ^JaJnHtH8h_]hji5B* CJOJPJQJ^JaJnHph `tH8h_]h9w5B* CJOJPJQJ^JaJnHph `tH8h_]h^5B* CJOJPJQJ^JaJnHph `tHx fhd(,,,,- Erdh*$9D^r`gd_]$dh7$8$H$a$gd_] Edh*$9Dgd_] Erd*$9D^r`gd+$dh1$`a$gd~aT$dh1$a$gde>k   TbdfǴymmmmmmmmmmZ$h~aTh7OJPJQJ^JnHtHh[oph^5OJQJ'h[oph^5OJPJQJ^JnHtH'h[oph76OJPJQJ^JnHtH$h[oph^OJPJQJ^JnHtH$h[oph9wOJPJQJ^JnHtH$h[ophZ$OJPJQJ^JnHtH$h[oph7OJPJQJ^JnHtH$h~aT5OJPJQJ\^JnHtHfhj P$%%&(d(*,,,,,T-V-X-Z-\-^-`-b-d-f-h-j-l-n-p-r-t-v-x-z-|-~-----ݻ{{{{{{{{{{{{{{{{{{{{{{{{{h[ophJzOJQJ8h[oph_]5B*CJOJPJQJ^JaJnHphtHUh[ophxOJQJh[oph_]OJQJCh[ophx56B*CJKHOJPJQJ^J_H9aJnHphtHCh[oph_]56B*CJKHOJPJQJ^J_H9aJnHphtH02) Wykonawc oraz uczestnika konkursu, ktrego beneficjentem rzeczywistym w rozumieniu ustawy z dnia 1 marca 2018 r. o przeciwdziaBaniu praniu pienidzy oraz finansowaniu terroryzmu (Dz. U. z 2022 r., poz. 593, ze zm.) jest osoba wymieniona w wykazach okre[lonych w rozporzdzeniu 765/2006 i rozporzdzeniu 269/2014 albo wpisana na list lub bdca takim beneficjentem rzeczywistym od dnia 24 lutego 2022 r., o ile zostaBa wpisana na list na podstawie decyzji w sprawie wpisu na list rozstrzygajcej o zastosowaniu [rodka, o ktrym mowa w art. 1 pkt 3 ustawy; 3) Wykonawc oraz uczestnika konkursu, ktrego jednostk dominujc w rozumieniu art. 3 ust. 1 pkt 37 ustawy z dnia 29 wrze[nia 1994 r. o rachunkowo[ci (Dz. U. z 2021 r., poz. 217, ze zm.) jest podmiot wymieniony w wykazach okre[lonych w rozporzdzeniu 765/2006 i rozporzdzeniu 269/2014 albo wpisany na list lub bdcy tak jednostk dominujc od dnia 24 lutego 2022 r., o ile zostaB wpisany na list na podstawie decyzji w sprawie wpisu na list rozstrzygajcej o zastosowaniu [rodka, o ktrym mowa w art. 1 pkt 3 ustawy. & & & & & & & & & & & & & & & & & & & & & & & & & & & (podpis Wykonawcy)     Strona PAGE1 z NUMPAGES2  Gmina Gorzw Zlski Strona PAGE1 z NUMPAGES2 ----...0.B.R.T.V.X.Z.\.^.`.b.d.f.h.j.l.n.p.r.t.v................yjhCJ^JaJmHnHu&jhCJU^JaJmHnHu h5CJ\^JaJnHtH)jh5CJU\^JaJnHtHhCJ^JaJnHtHhEjhEU8h[oph_]5B*CJOJPJQJ^JaJnHphtHh[oph_]OJQJh[ophJzOJQJ)-T.V.Z.\.^.b.d.f.j.l.n.r.t.v....$ $ %x*$a$gd$ $ %*$a$gd dgd eh Erdh*$9D^r`gd_] Edh*$9D^`gdJz......../////// /"/$/&/(/ʼʬʼʬܛv8h[oph_]5B*CJOJPJQJ^JaJnHphtHhEh#hQ hRhxwCJOJQJ^JaJh}5CJ\aJmHnHuh+h+5CJ\aJ#jh+h+5CJU\aJh+h+CJaJhC'hh+CJ^JaJmHnHtHu. /"/$/&/(/ Erdh*$9D^r`gd_]$a$gd}R$a$z+p8,p8-p8.p81+/R 48586878:p=. 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