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ATTACHMENT E <br />CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER <br />RESPONSIBILITY MATTERS <br />Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. <br />Applicants should also review the instructions for certification included in the regulations before completing this form. <br />Signature of this form provides for compliance with certification requirements under the applicable CFR covering New <br />Restrictions on Government -wide Debarment and Suspension (Nonprocurement). The certification shall be treated as a <br />material representation of fact upon which reliance will be placed when the Agency determines to award the covered <br />transaction or cooperative agreement. <br />As required by Executive Order 12549, Debarment and Suspension, and implemented under the applicable CFR, for <br />prospective participants in covered transactions, as defined in the applicable CFR <br />A. The applicant certifies that it and its principals: <br />(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of <br />Federal benefits by a State or Federal court, or voluntarily excluded from covered transactions by any Federal <br />department or agency; <br />(b) Have not within a three -year period preceding this application been convicted of or had a civil judgment <br />rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting <br />to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; <br />violation of Federal or State antitrust 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 indicted for or otherwise criminally or civilly charged by a government entity (Federal State <br />or local) with commission of any of these offenses enumerated in paragraph (1) (b) of this certification; and <br />(d) Have not within a three -year period preceding this application had one or more public transactions (Federal, <br />State or local) terminated for cause or default; and <br />B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an <br />explanation to t pp is on. <br />� � <br />Authorized Agent Signature <br />iC 6. o �/l FITI �viPL <br />Printed '� or yped�Iame <br />F- ,Ret— 4ttE_ <br />Title <br />Address: t �--( (YL 146 '0 /"t 7 <br />\ry� roc C4 0l2%UZ- <br />