Agenda - 04-03-1995 - VIII-G - Laserfiche WebLink

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U.S. Department of the interior 8 TO BE COMPLETED Certification Regarding BY GRANTEE Debarment, Suspension, and Other Responsibility Matters Primary Covered Transactions This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension,43 CFR Part 12, Section 12.510,Participants' responsibilities. The regulations were published as Part VII of the May 25, 1988 Federal Register(pages 19160-19211). Copies of the regulations are included in the proposal package: For further assistance in obtaining a copy of the regulations,contact the U.S. Department of the Interior, Acquisition and Assistance Division,Office of Acquisition and Property Management, 18th and C Streets,N.W.,Washington,D.C.20240. (BEFORE COMPLETING CERTIFICATION,READ INSTRUCTIONS ON REVERSE) (1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals: (a) Are not presently debarred,suspended,proposed for debarment, declared ineligible,or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining,attempting to obtain,or performing a public(Federal,State or local)transaction or contract under a public transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft,forgery,bribery,falsification or destruction of records,making false statements,or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(Federal,State or local)with commission of any of the offenses enumerated in paragraph(1)(b)of this certification;and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions(Federal,State or local)terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification,such prospective participant shall attach an explanation to this proposal. (Signature) Date Name and Title of Authorized Representative Name of Project 01.1953 (9/88)