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IW:III:3Yr_1 CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS Ap'pl'icants should refer to the regulations cited 'below to determine the certification to which they are required to attest. Applicants should also review the instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification requirements under the applicable CFR covering New Restrictions on Government -wide Debarment and Suspension (Nonproemement). The certification shall be treated as a material representation of fact upon which reliance will be placed when the Agency determines to award the covered transaction or cooperative agreement. As required by Executive Order 12549, Debarment and Suspension, and implemented under the applicable CFR, for prospective participants in covered transactions, as defined in the applicable CFR A. The applicant certifies that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, sentenced to a denial of Federal benefits by a. State or Federal court, or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three -year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fi °aud 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, malting false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal State or local) with commission of any of these offenses enumerated in paragraph (1) (b) of this certification; and (d) Have not within a three -year period preceding this application bad one or more public transactions (Federal, State or local) terminated for cause or default; and B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application. Authorized Age t Signature ht Printed or Typed Name Title Address: 1( -J) KA Obl ice Oqf 27 t3(-Aol ( "en TVtS�h o �)-%-'-O