5 HCSD Suspension

Haralson County School District Facilities/Maintenance Department

SUSPENSION AND DEBARMENT CERTIFICATION

1. All vendors, including sub-contractors, must complete this certification and certify under penalty of perjury that, except as noted below, certifies that it and its principals:

(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

(b) Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses listed above; and

(d) Have not within a three-year period preceding this application had one or more public transaction (Federal, State, or local) terminated for cause or default.

2. If such persons or vendors later become aware of any information contradicting the statements above, HCSD will be promptly notified.

3. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this certification.

Printed Name and Title of Officer authorized to sign on the company’s behalf:

Signature:__________________________________________________

Date:______________________________________________________

Name of Company:___________________________________________

**Return with complete RFP packet**