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• • <br />EXHIBIT A <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 <br />'required to attest. Applicants should also review the instructions for certification included in the regulations <br />before completing this form. Signature of this form provides for compliance with certification requirements <br />under the applicable CFR covering New Restrictions on Government-wide Debarment and Suspension <br />(Nonprocurement). The certification shall be treated as a material representation of fact upon which reliance <br />will be placed when the Agency determines to award the covered transaction or cooperative agreement. <br />As required by Executive Order 12549, Debarment and Suspension, and implemented under the applicable <br />CFR, for 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 <br />to a denial of Federal benefits by a State or Federal court, or voluntarily excluded from covered <br />transactions by any Federal department or agency; <br />(b) Have not within athree-year period preceding this application been convicted of or had a civil <br />judgment rendered against them for commission of fraud or a criminal offense in connection <br />with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction <br />or contract under a public transaction; violation of Federal or State antitrust statutes or <br />commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, <br />making false statements, or receiving stolen property; <br />(c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity <br />(Federal State or local) with commission of any of these offenses enumerated in paragraph (1) <br />(b) of this certification; and <br />(d) Have not within athree-year period preceding this application had one or more public <br />transactions (Federal, 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 <br />attach an explanation to this application. <br />-~ U. <br />Aut zed Agent Signat r <br />~~ <br />~~;' 11 ~ ~ IC1 ~-~ t-. <br />Printed or Typed Name <br />Title <br />Address: ~~ ~'~ <br />''~~;~,~r P~~~c!,E-l ,c~ <br /> <br />26 <br />