INTEGRITY CERTIFICATION.pdf

REQUIRED BID SUBMISSION FORM

INTEGRITY CERTIFICATION

Certification Regarding Debarment, Suspension and Other Responsibility Matters

The undersigned certifies to the best of their knowledge and belief that

(Company) and its principals:

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

(2) Have not within a three year period preceding this transaction 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 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;

(3) Are not presently indicated for or otherwise criminally or civilly charged by a government entity with commission of any of the offenses enumerated in paragraph (2) of this certification; and

(4) Have not within a three year period preceding this transaction had one or more public transactions terminated for cause or default.

certifies or affirms the truthfulness and

(Company) accuracy of the contents of the statements submitted on or with this certification and understands that the provisions of 31 U.S.C. Section 3801 ET SEO. are applicable thereto.

(Signature)

(Title)

(Date)