ࡱ>      Mbjbj!!KGiKGi!$$V(V(5"677777787l=9T7U \99:999s'tT{t,       gR 7t!rr@tt 161699@8 zzztH1695789 zt zzb6Jm790u`u: % 0U )vPR7L ttzttttt  yx2tttU tttttttttttttV(c 4:ZaBcznik nr 2 do SWZ O[wiadczenie WYKONAWCY skBadane na podstawie art. 125 ust. 1 ustawy Pzp o niepodleganiu wykluczeniu Wykonawca: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, Regon, KRS/CEiDG) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . (imi, nazwisko, stanowisko/podstawa do reprezentacji) Na potrzeby postpowania o udzielenie zamwienia publicznego prowadzonego w trybie podstawowym bez przeprowadzenia negocjacji, prowadzonego przez Gmin Strykw, ul. Tadeusza Ko[ciuszki 27, 95-010 Strykw, pn.  Projekt budowy drogi gminnej w Dobieszkowie znak: IZP.271.24.2023.JZ.PZP. o[wiadczam, co nastpuje: 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 ust. 1 pkt 1, 4, 5, 8 i 10 ustawy Pzp. 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. ............................, dn. _ _ . _ _ . _ _ _ _ r. & & .& & & & & & & & & & & & & & & & & & & & & & & ..& & . Podpis(y) osoby(osb) upowa|nionej(ych) do podpisania niniejszego o[wiadczenia w imieniu Wykonawcy(w). O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym OZWIADCZENIE WYKONAWCY W PRZYPADKU WYKLUCZENIA (na podstawie art. 108 ust. 1 pkt 1, 2 i 5 lub art. 109 ust. 1 pkt 2-5 i 7-10 ustawy Pzp) O [ w i a d c z a m, |e zachodz w stosunku do mnie podstawy wykluczenia z postpowania na podstawie art. & & & . ustawy PZP (nale|y poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych w art. 108 ust. 1 pkt 1, 2 i 5 lub art. 109 ust. 1 pkt 2-5 i 7-10 ustawy PZP). Jednocze[nie o[wiadczam, |e w zwizku z tym, i| podlegam wykluczeniu na podstawie ww. artykuBu, to zgodnie z dyspozycj art. 110 ust. 2 ustawy Pzp przedstawiam nastpujce dowody na to, |e podjte przeze mnie [rodki s wystarczajce do wykazania mojej rzetelno[ci:& & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & .. ....... ....... ....... ....... (nale|y poda dowody, |e podjte [rodki s wystarczajce do wykazania rzetelno[ci Wykonawcy) ............................, dn. _ _ . _ _ . _ _ _ _ r. & & .& & ................................................................... Podpis(y) osoby(osb) upowa|nionej(ych) do podpisania niniejszego o[wiadczenia w imieniu Wykonawcy(w). O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym 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. ............................, dn. _ _ . _ _ . _ _ _ _ r. & & .& & ................................................................. Podpis(y) osoby(osb) upowa|nionej(ych) do podpisania niniejszego o[wiadczenia w imieniu Wykonawcy(w). O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym O[wiadczenie PODMIOTU NA ZASOBY KTREGO POWOAUJE SI WYKONAWCA skBadane na podstawie art. 125 ust. 1 ustawy Pzp o niepodleganiu wykluczeniu UWAGA  przedmiotow cz[ o[wiadczenia skBada podmiot udostpniajcy swoje zasoby Wykonawcy. Je|eli nie wystpuje ww. podmiot  o[wiadczenie nie musi by zaBczane do oferty Podmiot udostpniajcy zasoby: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, Regon, KRS/CEiDG) reprezentowany przez: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . (imi, nazwisko, stanowisko/podstawa do reprezentacji) Na potrzeby postpowania o udzielenie zamwienia publicznego prowadzonego w trybie podstawowym bez przeprowadzenia negocjacji, prowadzonego przez Gmin Strykw, ul. Tadeusza Ko[ciuszki 27, 95-010 Strykw, pn.  Projekt budowy drogi gminnej w Dobieszkowie znak: IZP.271.24.2023.JZ.PZP o[wiadczam, co nastpuje: 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 ust. 1 pkt 1, 4, 5, 8 i 10 ustawy Pzp. 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O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym OZWIADCZENIE PODMIOTU NA ZASOBY KTREGO POWOAUJE SI WYKONAWCA W PRZYPADKU WYKLUCZENIA (na podstawie art. 108 ust. 1 pkt 1, 2 i 5 lub art. 109 ust. 1 pkt 2-5 i 7-10 ustawy Pzp) O [ w i a d c z a m, |e zachodz w stosunku do mnie podstawy wykluczenia z postpowania na podstawie art. & & & . ustawy PZP (nale|y poda majc zastosowanie podstaw wykluczenia spo[rd wymienionych w art. 108 ust. 1 pkt 1, 2 i 5 lub art. 109 ust. 1 pkt 2-5 i 7-10 ustawy PZP). Jednocze[nie o[wiadczam, |e w zwizku z tym, i| podlegam wykluczeniu na podstawie ww. artykuBu, to zgodnie z dyspozycj art. 110 ust. 2 ustawy Pzp przedstawiam nastpujce dowody na to, |e podjte przeze mnie [rodki s wystarczajce do wykazania mojej rzetelno[ci:& & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & ...& & & & & & & & & & & & & & & & .. (nale|y poda dowody, |e podjte [rodki s wystarczajce do wykazania rzetelno[ci Wykonawcy) ............................, dn. _ _ . _ _ . _ _ _ _ r. & & .& & ................................................................. Podpis(y) osoby(osb) upowa|nionej(ych) do podpisania niniejszego o[wiadczenia w imieniu Podmiotu na zasoby, ktrego powoBuje si Wykonawca. O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym 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. ............................, dn. _ _ . _ _ . _ _ _ _ r. & & .& & ................................................................... Podpis(y) osoby(osb) upowa|nionej(ych) do podpisania niniejszego o[wiadczenia w imieniu Podmiotu na zasoby, ktrego powoBuje si Wykonawca. O[wiadczenie w postaci elektronicznej winno by podpisane kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub podpisem osobistym  O[wiadczenia skBadaj wszyscy Wykonawcy wsplnie ubiegajcy si o zamwienie (np. konsorcjum, spBka cywilna tj. wsplnicy spBki cywilnej), ka|dy z Wykonawcw wsplnie ubiegajcych si o zamwienie skBada niniejsze o[wiadczenie oddzielnie (w przypadku spBki cywilnej nale|y zBo|y niniejsze o[wiadczenie w odniesieniu do ka|dego wsplnika spBki cywilnej oddzielnie).  Nale|y wskaza dane umo|liwiajce dostp do podmiotowych [rodkw dowodowych, ktre Zamawiajcy mo|e uzyska za pomoc bezpBatnych i oglnodostpnych baz danych, w szczeglno[ci rejestrw publicznych w rozumieniu ustawy z dnia 17 lutego 2005 r. o informatyzacji dziaBalno[ci podmiotw realizujcych zadania publiczne.  UWAGA!!! Je|eli w stosunku do Wykonawcy nie zachodz podstawy wykluczenia z postpowania, o ktrych mowa w niniejszym wzorze o[wiadczenia  o[wiadczenia nie nale|y podpisywa, mo|na wskaza NIE DOTYCZY, lub dokona skre[lenia tej cz[ci zaBcznika.  Nale|y wskaza dane umo|liwiajce dostp do podmiotowych [rodkw dowodowych, ktre Zamawiajcy mo|e uzyska za pomoc bezpBatnych i oglnodostpnych baz danych, w szczeglno[ci rejestrw publicznych w rozumieniu ustawy z dnia 17 lutego 2005 r. o informatyzacji dziaBalno[ci podmiotw realizujcych zadania publiczne.  UWAGA!!! Je|eli w stosunku do Podmiotu na zasoby, ktrego powoBuje si Wykonawca nie zachodz podstawy wykluczenia z postpowania, o ktrych mowa w niniejszym wzorze o[wiadczenia  o[wiadczenia nie nale|y podpisywa, mo|na wskaza NIE DOTYCZY, lub dokona skre[lenia tej cz[ci zaBcznika.     Gmina Strykw 95-010 Strykw, ul. 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