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36 <br /> CERTIFICATIONS REGARDING DEBARMENT,SUSPENSION AND OTHER <br /> RESPONSIBILITY MATTERS <br /> Applicants should refer to the regulations cited below.Applicants should also review the instructions for certification <br /> included in the regulations before completing this form,signature on this form provides for compliance with <br /> certificationrequirements implementing Federal Executive Order 12549 and guidance issued in the Federal Register, <br /> Volume 70,No, 168,pages 51863 through 51880 for "Governmentwide Debarment and Suspension(Nonprocurement)" <br /> The certification shall be treated as a material representation of fact upon which reliance will be placed when the <br /> Department of Commerce determines to award the covered transaction,grant or cooperative agreement. <br /> 1. DEBARMENT,SUSPENSION AND OTHER RESPONSIBILITY MATTERS <br /> As required by Executive Order 12549,Debarment and Suspension,for prospective participants in primary <br /> covered transactions. <br /> (1) The prospective primary participant certifies to the best of its knowledge and belief,that it and its principals: <br /> (a) Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily <br /> excluded from covered transactions by a Federal department or agency; <br /> (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment <br /> rendered against them for commission of fraud or a criminal offense in connection with obtaining, <br /> attempting to obtain,or performing a public(Federal,State or local)transaction or contract under a public <br /> transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft,forgery, <br /> bribery,falsification or destruction or records,making false statements,or receiving stolen property: <br /> (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity <br /> (Federal,State or local)with commission of any of the offenses enumerated in paragraph(1}(b)of this <br /> certification;and <br /> (d) Have not within a three-year period preceding this application/proposal had one or more public <br /> transactions(Federal,State,or local)terminated for cause or default. <br /> (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, <br /> such prospective participant shall attach an explanation to this proposal. <br /> As the duly authorized representative of the applicant,I hereby certify that the applicant will comply with the above <br /> applicable certification(s). <br /> NAME OF APPLICANT AWARD NUMBER AND/OR PROJECT NAME <br /> Orange County,NC Morinaga America Foods, Inc. Infrastructure <br /> PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE <br /> Mr. Barry Jacobs, Chair, Orange County Board of Commissioners <br /> SIGNATURE DATE <br /> CDBG-ED Debarment Certification Form Section 33 <br />