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24 <br /> U.S. DEPARTMENT AGRICULTURE <br /> Certification Regarding Debarment, Suspension,and Other <br /> Responsibility Matters-Primary Covered Transactions <br /> This certification is required by the regulations implementing Executive Order 12549,r ebarmer t and Suspension,7 <br /> CFR Part 3017,Section 3017.510,P -ti c i pants"responsibilities.The regulations were published as Part IV of the <br /> January 30, 19S9, 'ederal fie aster(pages 47224733).Copies of the regulations may be obtained by contacting the <br /> Department of Agriculture agency offering the proposed covered transaction. <br /> (BEFORE CCOMPLETING TI TI I ' TI N,READ INSTRUCTIONS <br /> (l) The prospective primary participant certifies to the best of its knowledge and belief,that it and its <br /> principals: <br /> (a)are not presently debarred,suspended,proposed for debarment,declared ineligible,or <br /> voluntarily excluded from covered transactions by any Federal department or 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 crirn inal 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 Fed- <br /> eral or State antitrust statutes or commission of embezzlement,theft,forgery, <br /> bribery,falsification or destruction of records,making false statements,or receiving <br /> stolen property; <br /> (c)are not presently indicted for or otherwise criminally or civilly charged by a <br /> governmental entity(Federal,State or local)with commission of any of the offenses <br /> enumerated in paragraph(1)(b)of this certification;and <br /> d)have not within a three-year period preceding this application/proposal had one or <br /> more public 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 <br /> certification,such prospective participant shall attach an explanation to this proposal. <br /> ORANGE COUNTY <br /> Organization Name PR/ and Number or Project Name <br /> ame(s)and Title(s)of Authorized Representative(s) <br /> Signature(s) 4 — ~ <br /> Date <br /> Form AD- 1047(1/92) <br />