Attachment G
<br /> b '1 . , 4 M {. �t .i44bM � N �4Y JP '� '�;'�r( }*./i�.b[+ 44 f a4" tY t Yi'x 'Z \\'F Sy1 ;?�+h✓
<br /> 1 'v3M�R� A
<br /> x �.` ,vik{ +sitir3bf d +Rra � a64 .'u^ a sla- 7o-+.,lfi ^ ks ,syfifFe. t "k a$t �:i�[i'f° '� 4�`h 'iryi ,;•,,- 5 +
<br /> ,,J. wY y '1 'JrrV 4,11
<br /> rS:.
<br /> 4 sY .t. ,� � \ryrit ✓ , it `i :�, i� � �! V ' Y�$ " Ff J/Nt. Y� Jr,� wPCa! kN :.YM hlJ
<br /> €.. . erre r. i .t�laxdy nCeHfificatHo�Hetegardan�gx' *
<br /> s(i f� YK';Y �' 1.� >'S� F `':,{� fis ro,? ��A refs ht F� c s'a� �t '��.w.�aa';+%,"' 'E a'Fi' >:`a�'f. �vdYi ,� o.'�+9 • f�,�
<br />: n }. . Y �`'x� 2F m �m'�,'7 ..
<br /> +-
<br /> tl3 Y, '� _!?z 3'`. , r' i";: S 'h''i ^se�` � y�iw� ,. . rri`'1 .r�� ";�fp �➢ax �',��'^�k�F'ati =�fi �5 rt �ax.a:.�� n,`i'�°'�`'�'r'���S'y*���.r"
<br />i,,, ,� +`�`,�rr�.r }�$ .a� ',k,yc...'�: '�>Kh , , . ryra.F r xsx�rs.
<br /> � sC >r r?. r s .n. a. . 'k'� et +✓ � i d� � � i t;{: a a H r64 Nw" E r, : . .se*izl�y�ry"XI�`� r y .I�f�'' b"w
<br />��Ct"• Y ^h�a�,� 3f �-,n5,1�5' '��`.h' a
<br /> +. C ' J `� / - . '�,cw�F'xaS . . 3•� r i a � �r y � �t'gChHr7H®IH >x �Lr 4.. ^z `�." 74`S+y`�",� �
<br /> �'
<br /> + r ' r*d i� " �� '`f ar1� �r tv9�'E���:� x��.. ��s��"��`�^�jHrll�r�Y,,.��Ylunta�✓2'�. ,Sn ` ,�,"".xg""�,e?mn�hY:n'2^ nkt�'�tso�i�� �"u'tu�'ti�i�,''��"�'hr+
<br />r�.Sa'ex'^^�..'s+�m.r-v`!�v a` 4'�
<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 -4X40 -40 - 01 -F 13
<br /> (Print Name and Title) (DCA Contract Number)
<br /> ( Street Address )
<br /> (City , State, Zip)
<br /> 24
<br />
|