ࡱ> c0bjbjNN4B$i$iN  mmmmm8d,n("II(qqq  '''''''*F-p'9m'mmqqH((]]]Fmqmq']']]V$@i%q13F$ '>(0n($x-y-i%-mi%p]''Dn(- c 3:ZaBcznik nr 3 do SWZ (o[wiadczenie wstpne) Zamawiajcy: Gmina Kkolewnica ul. Lubelska 5, 21-302 Kkolewnica Wykonawca /czBonek konsorcjum/ podmiot na zasoby ktrego powoBuje si wykonawca w celu speBnienia warunkw udziaBu w postpowaniu*: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & .. (imi, nazwisko, stanowisko/podstawa do reprezentacji) *niepotrzebne skre[li 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 NIEPODLEGANIA WYKLUCZENIU ORAZ SPEANIANIA WARUNKW UDZIAAU W POSTPOWANIU Na potrzeby postpowania o udzielenie zamwienia publicznego pn. Zakup wyposa|enia sali integracji sensorycznej w ramach projektu  Wsparcie edukacji w Gminie Kkolewnica , prowadzonego przez Gmin Kkolewnica, o[wiadczam, co nastpuje: O[wiadczam, |e nie podlegam wykluczeniu z postpowania na podstawie art. 108 ust. 1 ustawy Pzp. O[wiadczam1, |e zachodz w stosunku do mnie podstawy wykluczenia z postpowania na podstawie art. & & & & . ustawy Pzp (poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych wart. 108 ust. 1 pkt 1, 2 i 5 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: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. 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U. poz. 835). O[wiadczam2, |e speBniam warunki udziaBu w postpowaniu okre[lone przez Zamawiajcego wspecyfikacji warunkw zamwienia, RozdziaB VIII. O[wiadczam, |e wszystkie informacje podane w powy|szych o[wiadczeniach s aktualne i zgodne zprawd oraz zostaBy przedstawione z peBn [wiadomo[ci konsekwencji wprowadzenia Zamawiajcego w bBd przy przedstawianiu informacji. .......................................................................... & & & & & & & & & & & & & & & & & & & & & & & & .. (miejscowo[, data) (podpis) 1wypeBni, je|eli dotyczy 2w przypadku wykonawcw ubiegajcych si wsplnie o udzielenie zamwienia o[wiadczenie o speBnianiu warunkw udziaBu w postpowaniu skBadane jest w zakresie, w jakim ka|dy z wykonawcw wykazuje speBnianie warunkw udziaBu wpostpowaniu, a w przypadku podmiotu trzeciego udostepniajcego wykonawcy swoje zasoby o[wiadczenie skBadane jest w zakresie, w jakim wykonawca powoBuje si na jego zasoby.     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