Laserfiche WebLink
APPENDIX D <br /> 4121, <br /> !.!J IN r • f MA J <br /> ji�✓�n�v ! : • ! !s. a <br /> 3' Q" <br /> Y <br /> yr <br /> �a <br /> Subcontractor Covered Transactions <br /> ( 1 ) The prospective subcontractor of the Recipient, , <br /> certifies , by 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 Recipient's subcontractor is unable to certify to the above statement, the <br /> prospective subcontractor shall attach an explanation to this form. <br /> SUBCONTRACTOR: <br /> By: <br /> Signature Recipient's Name <br /> 10DB4X- 10-40-01 -F 13 <br /> Name and Title DCA Contract Number <br /> Street Address <br /> City, State , Zip <br /> Date <br />