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4W 40 I• U.S. Deppdftmsnt at the Inlsrfor Certtficatlons Regarding Debarment, Suipension and Other Responsibillty (Matters, Drug -Free Workplace Requirements fl i+rt Lobbying persons signing this form shoutd refer 10 the regulations referenced below for Clsmplcte instructions: Certification Regarding Debarment. Suspensor, aril Other Responsibility Matlera • primary Covered Transactions - The prospective primary participant further agrees by submitting this proposal that It will Include tics clause titled, "Caatiilcatlon Regarding Debarment, Suspenoton, InellgiNflty and Voluntary Exciuslan • Lower Tler Covered Transaction," provided by tree department or agency cantering into We covered b-ansaction, without modification, In sit lowar tier covered transactians and In all solictiations for lower tier covered transactions. See Wow for language to be used; use this farm for certification and sign: of use Department of lkre Inlena Form 1954 (01• 1954). (Sea Appendix A of Subpart D of 43 CFR Part 12.) Cerb5calion Regarding Oebarment. Suspension. Inetig,b+tdy and Voluntary Exclusion • Lower firer Covered Transactions (See Appendix B of Subpart 0 of 43 CFR Part 12.) Certification Regarding Ortrg•Froe V0xkt lac* Requnrnontf Aftemate I. (Grantees Other Than iniSividuals) and A1lemale e (Grantees "io are Irxfividuals) (S -,e Appendix C of Subpart 0 of 43 CFR part 12) Signature on tris form provides for OXNAarrce wAhh certiECB"lion requvernents under 43 CFR parts 12 and 19. The oertAcations shag be treated as a mate naI representation of fact upon when refrance wil bre ptaced wticn the Ocpartment of the interior determines to award the covered transaction, grarC coopefatn a agreement or loan. PART A- Certification Re dii rdng Debarment eb m ent, Suspension, and Otter Responsibility Matters primary Covere CIE CK__]F FrniS CER TIMA FION iS FORA MMARY COVERED TRMSAC iKW Aho fS APPr rr`JAr F (1) The prosp — ,r01arY panicipanl cenities to the best of its knowledge and belief, that d and its pdr6pais: (a) Are r -t pfesentry debarred. susperAW. proposed for debarrnont, dedarcC kl,05901e, or valuntanly excluded from cover d transactions by any Federal department tx agency; (b) Ha. :not within a Tvee-year period preoedog this proposal been convided of or had a 64 Kidgmaint rnndercd against them for commission of fraud or a orvninal offense in connection with obtaining, attempting to obtain. or performing a public (Federal. State or kocafl transaction or contract under a public transaction, violation of Federal of State anikrusl statutes or tonnnission of embezztement. theft, forgery• bnbery, falsification or destruction of records, making fatse stalernents, of recerving stolen property; (c) Are not presentty indicted for or otherwise crvrvnafiy or cmay charged by a governmental enlAy (Federal. State or local) with commission of any of the offenses enumerated in paragraph (I)jb) of this certification. and (d) Have not within a three-year period preceding this appOcatioNproposal had one of more public transaction i (Federal. State or local) terminated for cause or default. ?y 4 rt:erc is thin nfn;; r�ros rrirr:ainj participanl unahl� to certify to any of the slafemcnis in this certification, such piospecIM participant shall attach an exptanalion fe this Pro POS 'sf. pART B. Carter TfJon Re ed ing oerransacme t, Suspension, Ineligibility and Voluntary Exclusion r NECK—IF 7)1;S CEP Frr1CA TION IS FOR A J.OVWP DFR COVERED MANSAUION AND IS APPUCAfstE. r1; Y1;9 Pfosperriva lower tier participant certifies, by submission of this proposal, that norther it ria firs prinrxpars is Presently debarred, suspended, Pf0P*sed Ear debarment, doodled .iW::b!-_ cx yi;!14nlarvy e;riwFied 1f4C PnNaC3Uca in this Vensatl.rn by any Federal department or agervyr. (21 Vov.,e are prospeCLiva low• -r tier partk*2ni is unaWa to cent fy to any of the staterwrils in this certftalian, such prosptcWe partklipant shall attach an explanation to this, proposal. N FSM ■vMRlMlar lr rlq