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Attachment G <br /> t y �- =3°i t �"1' F�F+'h1+112H F + ry wr rxY ! ue <br /> $ o rr } s*, Pyl#F .. + s <br /> 00 <br /> ��jj p �s'faPv.. � i 4�- r ..R..:e.t^1. h2 n.F rte, yw:T "$ . . ^�3+"•"y 5 ,. vii tr J <br /> ,r r tea °r , agge.>l w xt 0.a.�, Cikffi* on <br /> (] ]►' v 2a u + r {� s c�Fs�. + <br /> CC5 Cg.1I " . <br /> 'I scT-'i %- <br /> M t= nar-3 '• s++F ,n t ' ' {li ygv 'tm y erc s y t." r� `' WyG ''dS' xd... <br /> - �i'y u f r >ax e RbL k �s G R�.,� rv?r a v <br /> pfn s r2`,Yr`°' res ai Ssr d, rz � '. �W ` 3x. r 5 Rol, rr'a. fi } :' <br /> { r 3 N ser .s . ,, m , d�, a a <br /> f .=i",tsx{Ffy rs.gF" k� ssya5ra . -2 +.` xxprrn 'a x rq ` .u�' }t��, iJ <br /> bearment �Suspejis� on lone i elf <br /> }} ♦ g'�f t 4 r t ZUNI f <br /> psi 4 ' E` r = i l g v#Y # i �5'ti tr <br /> 46 [�`, F�Pf <br /> :t h4.�1°s' r}j3laf <br /> 4 -W, Oor} zi <br /> And `dol <br /> Subcontractor Covered Transactions <br /> ( 1 ) The prospective subcontractor of the Recipient, , certifies , by <br /> submission of this document, that neither it nor its principals is presently debarred, <br /> suspended, proposed for debarment, declared ineligible, or voluntarily excluded from <br /> participation in this transaction by any Federal department or agency . <br /> (2) Where the Contractor ' s subcontractor is unable to certify to the above statement, the <br /> prospective contractor shall attach an explanation to this form. <br /> ( Sub- Contractor ' s Name) (Recipient ' s Name) <br /> Date : <br /> (Authorized Signature) <br /> lODB -4X- 10 -40-01 -F 13 <br /> (Print Name and Title) (DCA Contract Number) <br /> ( Street Address ) <br /> (City , State, Zip ) <br /> 24 <br />