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~11~QC,~ ~Cf~ ~ 4 9 <br />Certification Regarding Debarment, Suspension, and Other Responsibility Matters <br />Primary Covered Transactions <br />This certification is required by the regulations implementing F~cecutive Order 12549, Debarment and <br />Suspension, 13. CFR Part 145. The regulations were published as Part VII of the May 26, 1988 Federal <br />Register (pages 19160-19211). Copies of the regulations are available from local offices of the U.S. Small <br />Business Administration. <br />{BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE) <br />1. The prospective primary participant certifies to the best of its knowledge and belief that it and <br />its principals: <br />a. Are not presently debar-ed, suspended, proposed for disbarment, declared ineligible, or <br />voluntarily excluded from covered transactions by any Federal department or agency; <br />b. Have not within athree-year period preceding this application been convicted of or had a <br />civil judgment rendered against them for commission of fraud or a criminal offense in <br />connection with obtaining, attempting to obtain, or performing a public (Federal, State, or <br />local) transaction or contract under a public transaction; violation of Federal or State <br />antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or <br />destnsction of records, making false statements, or receiving stolen property; <br />c. Are not presently indicted for or otherwise criminally or civilly charged by a governmental <br />entity (Federal, State, or local) with commission of any of the offenses enumerated in <br />paragraph (1)(b) of this certification; and <br />d. Have not within athree-year period preceding this application had one or more public <br />transactions (Federal, State, or (Deaf) terminated for cause or default. <br />2. Where the prospective primary participant is unable to certify to any of the statements in this <br />certification, such prospective primary participant shall attach an explanation to this proposal. <br />Business Name: <br />Date: <br />By: <br />Name ~ Title of Authorized Representative <br />Signature of Authorized Representative <br />