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_t or CZI?. <br />Debarment/Suspension Verification <br />(Required Document fdr Award Recommendations/Purchases/Contracts) <br />Cuyahoga. County Department Field Buyer/Requestor: Please complete this form and, upload into the Procurement software <br />system. <br />Company Name <br />(Legal name of the <br />MAYFIELD VILLAGE <br />Business/Entity): <br />Company Principal <br />Owner/Contact's Name <br />RONALD C. WYNNE <br />(Please print clearly) <br />Principal Owner/Contact's Title: <br />DIRECTOR OF .FINANCE <br />Business Address: <br />6622 WILSON MILLS ROAD MAYFIELD VILLAGE OH 44143 <br />Phone Num. r: <br />440-4,42-1762 <br />CUYAHOGA COUNTY STAFF: <br />I certify that I have checked the Cuyahoga County Inspector General Debarment and Suspension lists on the Internet <br />(https °//inspectorgeneral cuyahoQacounoy us/) and they did not contain the above detailed vendor andlor principal <br />owner. <br />Check box below if applicable: <br />❑ *For Federally funded and Grant funded items only: I have also checked the Federal Debarment/Suspension list at <br />URL: htt�s 7/wwry sam goy/portal/SAM/#1 #1 and they did not contain the above detailed vendor andlor principal owner. <br />*When at the site, first "search" the name of the entity in "Quick Search" - it is not necessary to log -in. If they are listed <br />as an "Exclusion" - they are suspended or debarred and must not be utilized. If they are listed as an "En tity,"they are <br />OK to access. <br />(Form is to be dated within 60 days from the Department approval in the Procurement software system for the current purchase.) <br />Field Buyer Signature: <br />Printed Name: <br />Name of Cuyahoga County employee <br />completing this form (if different from above): <br />Cuyahoga County <br />(FDS Farm, 10-01-2015) <br />Date: <br />