# Annexure A — No-Blacklist Self-Declaration

*(To be reproduced on Cithorum [INDIA LEGAL SUFFIX] letterhead, signed by an authorised signatory, and submitted with every tender response.)*

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[Cithorum [INDIA LEGAL SUFFIX] Letterhead]

Ref: [TENDER REF NO]

To,
[Designation — e.g. The Chief Manager, Information Technology Department]
[Issuing Authority Full Name]
[Issuing Authority Address]

**Subject:** Submission of No-Blacklisting Self-Declaration for Tender Reference No. [TENDER REF NO] — "[TENDER TITLE]"

Dear Sir/Madam,

We, Cithorum [INDIA LEGAL SUFFIX], having our registered office at [REGISTERED OFFICE ADDRESS], do hereby declare and affirm that:

1. We have not been blacklisted, debarred, or suspended by any Government Department, Agency, Public Sector Undertaking, Autonomous Body, Statutory Authority, or any other entity of the Government of India or of any State Government in India as on the date of submission of this bid.

2. We have not been blacklisted, debarred, or suspended by any Multilateral or Bilateral Funding Agency, the World Bank Group, the Asian Development Bank, or any equivalent international body as on the date of submission of this bid.

3. No criminal proceedings, civil suits, or arbitration proceedings of a nature that would impair our ability to perform the obligations under the proposed contract are pending against the company or its directors.

4. We are not in liquidation, court receivership, or under any insolvency proceedings.

5. We undertake that we shall promptly inform the Issuing Authority in writing if at any time during the validity of our bid or during the term of any resulting contract, any of the above declarations cease to be true.

We understand that any false statement or material omission in this declaration shall constitute grounds for immediate disqualification of our bid, forfeiture of EMD (where applicable), termination of any contract awarded, and such other action as the Issuing Authority may deem fit including blacklisting and recovery of damages.

Yours faithfully,

For Cithorum [INDIA LEGAL SUFFIX]

[Authorised Signatory Name]
[Designation]
Date: [DD/MM/YYYY]
Place: [PLACE]

[Company Seal]

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*Filing notes (internal — remove before submission):*

- Reproduce on full company letterhead with footer including CIN, GST, registered address, contact details.
- Sign in blue ink. Affix company round seal across signature.
- Do **not** post-date or back-date.
- For tenders that prescribe their own format, copy the prescribed wording verbatim and only adapt the company details. Substantive deviations from prescribed annexure formats are common cause for rejection under "non-compliant".
