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r <br /> rSECTION 00640 — CERTIFICATION REGARDING DEBARMENTS SUSPENSION <br /> INELIGIBILITY , AND VOLUNTARY EXCLUSION — LOWER TIER FEDERALLY FUNDED <br /> TRANSACTIONS <br /> REQUIRED FOR ALL CONTRACTORS AND SUBCONTRACTORS <br /> 1 <br /> 1 . The undersigned hereby certifies that neither it nor its principals is presently debarred , <br /> r suspended , proposed for debarment , declared ineligible , or voluntarily excluded from <br /> participation in this transaction by any Federal department or agency. <br /> 2 . The undersigned also certifies that it and its principals : <br /> ' (a ) Have not within a three-year period preceding this response been convicted of <br /> or had a criminal offense in connection with obtaining , attempting to obtain , or <br /> performing a public ( Federal , State or local ) transaction or contract under a <br /> ' public transaction ; violation of Federal or State anti-trust statutes or commission <br /> of embezzlement , theft , forgery, bribery, falsification or destruction of records , <br /> making false statements , or receiving stolen property. <br /> ( b ) Are not presently indicted for or otherwise criminally or civilly charged by a <br /> governmental entity ( Federal , State or local ) with commission of any of the <br /> offenses enumerated in paragraph 2 . (a ) of this Certification ; and <br /> (c) Have not within a three-year period preceding this certification had one or more <br /> ' public transactions ( Federal , State or local ) terminated for cause or default . <br /> 3 . Where the undersigned is unable to certify to any of the statements in this certification , <br /> ' an explanation shall be attached to this certification . <br /> Dated this day of , 20 <br /> 1 <br /> ' BY <br /> Authorized Signature/Contractor <br /> ' Typed Name/Title <br /> ' Contractor's Firm Name <br /> ' Street Address <br /> ' Building , Suite Number <br /> City/State/Zip Code <br /> r <br /> Area Code/Telephone Number <br /> ' DEP FORM 11 -043 Rev(05/95) <br /> 00640- 1 <br /> 00640 — Debarments , Suspension , Ineligibility, etc. <br /> ' F:\Engineering\Capital Projects\0378-26th Street Bridge\0378-26th . Street Bridge CONTRACT DOC\0378-00640 - Debarments , <br /> Suspension , Ineligibility, etc.doc <br />