ࡱ> :=789Q@(bjbjaa84 e e}DD########8#<$$$#+FH$H$^$^$^$%d ((\EEEEEEE$ HJRE9#)%%))E##^$^$HE,,,)#^$#^$E,)E,,=?^$qG+.>"rEE0+F>K,vK,??JK#@T)),)))))EE,:)))+F))))K)))))))))D b":ZaBcznik nr 6 do SWZ Gmina Dbno ul. Marsz. J. PiBsudskiego 5 74 -400 Dbno 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 11.09.2019 r. Prawo zamwieD publicznych (dalej jako: ustawa Pzp), DOTYCZCE PRZESAANEK WYKLUCZENIA Z POSTPOWANIA Na potrzeby postpowania o udzielenie zamwienia publicznego pn:  Rozbudowa {Bobka Gminnego w Dbnie- cz[ 2 Zakup i dostawa wyposa|enia prowadzonego przez Gmin Dbno, ul. Marsz. J. PiBsudskiego 5, 74-400 Dbno o[wiadczam, co nastpuje: INFORMACJA DOTYCZCA WYKONAWCY: O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 108 ust. 1 ustawy Pzp. O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 109 ustawy Pzp w zakresie jaki Zamawiajcy wymagaB. O[wiadczam, |e nie podlegam wykluczeniu z postpowania w zwizku z okoliczno[ciami wskazanymi w *.DF~x : < ɷsaOsAsa4hyh[OJQJ^Jh[CJOJQJ^JaJ#hyh[>*CJOJQJ^JaJ#hyh[6CJOJQJ^JaJ hyh[CJOJQJ^JaJhk5CJOJQJ^JaJhk5CJOJQJ^JaJ)hhk5CJOJQJ\]^JaJ#hk5CJOJQJ\]^JaJ#hyh[5CJOJQJ^JaJ#h&h.`5CJOJQJ^JaJ#h&h[5CJOJQJ^JaJ,.Fx : < j $dhxa$gdxhgd? 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(miejscowo[),dnia & & & & .& & . r. O[wiadczam, |e zachodz w stosunku do mnie podstawy wykluczenia wymienione poni|ej z postpowania na podstawie art. & & & & . ustawy Pzp(poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych w art. 108 ust. 1 pkt 1, 2, 5 ustawy Pzp lub art. 109 ustawy Pzp). 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. OZWIADCZENIE DOTYCZCE PODANYCH INFORMACJI: O[wiadczam, |e wszystkie informacje podane w powy|szych o[wiadczeniach s aktualne i zgodne z prawd oraz zostaBy przedstawione z peBn [wiadomo[ci konsekwencji wprowadzenia zamawiajcego w bBd przy przedstawianiu informacji. & & & & & .& & . (miejscowo[),dnia & & & & & & & . r.       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