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U . S . Department of the interior TO BE COMPLETED BT : GR.ANTEE Certification Regarding 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 VU of the May 25 , 1988 Federal Register ( pages 19160. 19211 ) . Copies of the regulations are included in the proposal package . For further assist i ancen obtaining a copy of the regulations , contact the U . S . Department of the Interior, Acquisition and Assistance Division , Office of Acquisition aad Property Ma.nagement, 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 theses for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain , or performi ng a public ( Federal, State or local) transaction or contract under a public transaction , violation of Federal or State antitrust statutes or commission of esabezzleaneat, theft, forgery, bribery , falsification or destruction of records, making false statements , or receiving stolen property ; ( c ) Are not presently indicted for or otherwise cri, =nally or civilly charged by a govern mental entity ( Federal, State or local) with commission of any of the offenses enumerated in paragraph ( 10 ) 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 &hall attach an explanation to this proposal. gnature . o Grantee Date Name and Title of Authorized Representative Name of Project O1. 19S3 (9418 )