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<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 />
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