U.S.
TRADE AND DEVELOPMENT AGENCY
ATTACHMENT B
USTDA-Funded Feasibility Study, Technical Assistance, or Training Grant
Subcontractor Information Form
This form is designed to enable the U.S. Trade and Development Agency ("USTDA") to obtain information about entities and individuals proposed for participation in USTDA-
funded activities. Information in this form is used to conduct screening of entities and individuals to ensure compliance with legislative and executive branch prohibitions
on providing support or resources to, or engaging in transactions with, certain individuals or entities with which USTDA must comply.
USTDA Activity Number [To be completed by
2023-31019A
USTDA]
Activity Title [To be completed by USTDA] Indonesia: West Sumbawa Wind Power Plant FS
1. Full Legal Name of U.S. Prime Contractor for
PT SENTRA PRIMA SERVICES
USTDA Activity
2. Full Legal Name of Subcontractor (as stated in
articles of incorporation or equivalent legal
document)
3. Business Address of Subcontractor Unimas Garden Regency Jl Imermotors 1 blok B-06 Waru Sidoarjo 61256
Indonesia
4a. Subcontractor Telephone Number +62 31 8553205
4b. Subcontractor Website
5. Year Subcontractor Established (include any
predecessor company(ies) and year(s) established). Please
attach additional pages as necessary.
Subcontractor Point of Contact
6. Full Legal Name (First, Middle, Last/Family) Puspito Nugroho Buntoro
7. Family Name or Last Name
8. Address Griyo Mapan Sentosa blok FA1 no 9 Tropodo Waru Sidoarjo 61256
Indonesia
9. Telephone +62 817 9948 999
10. Email piton@[Link]
Subcontractor may attach additional sheets, as necessary.
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U.S. TRADE AND DEVELOPMENT AGENCY
Subcontractor’s Representations
Initial
The Subcontractor shall provide the following (or provide any explanation as to why any representation cannot be made), made as of the below
date of these representations:
A. Subcontractor is a
[check one]
LJv
Corporation
LJ LJ LLC Partnership
duly organized, validly existing and in good standing under the laws of:
I I
Sole
Proprietor
I
I I
Other
(specify):
11. Insert US State or Country
I
Specify Type of Entity
The Subcontractor has all the requisite corporate power and authority to conduct its business as presently conducted, to participate Initial Here
in this USTDA-funded activity, and if the U.S. Prime Contractor is selected, to execute and deliver a subcontract to the U.S. Prime
Contractor for the performance of the USTDA- funded activity. The Subcontractor is not debarred, suspended, or to the best of its
knowledge or belief, proposed for debarment or ineligible for the award of contracts or multilateral assistance under the laws of the U.S.
or any other law.
B. Neither the Subcontractor nor any of its directors or principal officers have, within the ten-year period preceding the submission of
these representations, been convicted of or had a judgment rendered against them for: commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a federal, state, or local government contract or subcontract;
Initial Here
violation of federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, tax evasion, violating federal or state criminal tax laws, or
receiving stolen property.
C. Neither the Subcontractor, nor any of its directors or principal officers, is presently indicted for, or otherwise criminally or civilly
Initial Here
charged with, commission of any of the offenses enumerated in paragraph B above.
D. There are no federal or state tax liens pending against the assets, property, or business of the Subcontractor. The Subcontractor has
not, within the three-year period preceding the submission of these representations, been notified of any delinquent federal or state
taxes in an amount that exceeds US$10,000 for which the liability remains unsatisfied. Taxes are considered delinquent if (a) the tax Initial Here
liability has been fully determined, with no pending administrative or judicial appeals; and (b) a taxpayer has failed to pay the tax
liability when full payment is due and required.
E. The Subcontractor has not commenced a voluntary case or other proceeding seeking liquidation, reorganization, or other relief with
respect to itself of its debts under any bankruptcy, insolvency, or other similar law. The Subcontractor has not had filed against it an Initial Here
involuntary petition under any bankruptcy, insolvency, or any similar law.
The selected Subcontractor shall notify the U.S. Prime Contractor and USTDA if any of the representations are no longer true,
correct, and complete during the period of the Subcontractor’s involvement in the above-captioned Activity.
The Subcontractor certifies that the information provided in this form is true, correct, and complete. The Subcontractor understands and agrees that the U.S.
Government may rely on the accuracy of this information in processing a request to participate in a USTDA-funded activity. If at any time USTDA has reason to believe
that any person or entity has willfully and knowingly provided incorrect information or made false statements, USTDA may take action under applicable law. The
undersigned represents and warrants that he/she has the requisite power and authority to sign on behalf of the Subcontractor.
12. Name 15.
Signature
13. Title
14. Full Legal Name of 16. Date
Subcontractor
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