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I' <br /> ATTACHMENT NO.2 <br /> SRF Project No. <br /> ' Owner/Recipient: <br /> CERTIFICATION REGARDING " <br /> DEBARMENT,SUSPENSION AND OTHER RESPONSIBILITY MATTERS <br /> This form must be completed for each prime and subcontractor;and submitted to the State <br /> Infrastructure Finance Section, 1633 Mail Service Center, Raleigh,North Carolina 27699-1633. <br /> The prospective 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, <br /> nor voluntarily excluded from covered transactions by any Federal department or <br /> agency; <br /> (b) Have not within a three-year period preceding this proposal been convicted of or had <br /> a civil judgment rendered against them for commission of fraud or a criminal offense <br /> ' in connection with obtaining,attempting to obtain,or performing a public(Federal, <br /> State or local)transaction or contract under a public transaction;violation of Federal or <br /> State anti-trust statutes or commission of embezzlement,theft,forgery, bribery, <br /> ' falsification or destruction of records,making false statements,or receiving stolen property; <br /> (c) Are not presently indicated for or otherwise criminally or civilly charged by a government <br /> entity,(Federal,State or local)with commission of any of the offenses enumerated in <br /> paragraph (1)(b)of this certification;and <br /> I <br /> (d) Have not within a three year period preceding this application/proposal had one or more <br /> public transactions(Federal,State or local)terminated for cause or default. <br /> understand that a false statement on this certification may be grounds for rejection of this proposal or <br /> ' termination of the award. In addition,under 18 U.S.C. 1001,a false statement may result in a fine of up <br /> to$10,000 or imprisonment for up to five years,or both. <br /> I <br /> Name& itle of Authorized Representative and Name of Company <br /> ' Sig ure of uthorized Representative Date <br /> I am unable to certify to the above statements. Attached is my explanation. <br /> Prime or Subcontractor's Name: <br /> Telephone Number: <br /> i <br /> j <br /> i <br /> I <br /> i <br />