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, , ' U.S.Department of the Interior
<br /> Certifications Regarding Debarment, Suspension and
<br /> - Other Responsibility Matters, Drug-Free Workplace
<br /> : � Requirements and Lobbying
<br /> Persons signing this form should refer to the regulations Certification Regarding Debarment,Suspension,Ineligibility and
<br /> referenced below for complete instructions: , Voluntary Exclusion - Lower Tier Covered Transactions- (See
<br /> � CeRification Regarding Debarment, Suspension, and Other Append"a B of Subpart D of 43 CFR Part 12.)
<br /> Responsibility Matters - Primary Covered Transactions - The Certification Regarding Drug-Free Workplace Requirements -
<br /> prospective primary pa�ticipant turther agrees by Alternate I. (Grantees Other Than Individuals) and Altemate II.
<br /> submitting tf�is p�oposal that it will include the clause titled, (Grantees Who are Individuals)-(See Append'a C of Subpart D
<br /> "Certification Regarding Debarment, Suspension, of 43 CFR Patt 12)
<br /> I�eligibility and Voluntary Exclusion-Lower Tier Covered Signature on this form provides for compliance with certification
<br /> Transaction," provided by the department o� agency requirements under 43 CFR Parts 12 and 18. The ce�tifications
<br /> entering inbo this covered transaction,without mod�cation. shap be Veated as a material representation of fact upon which
<br /> in all bwer tier covered transactions a�d in all solicitations reliance will be placed when the Department of the�Interior
<br /> for lowe�tie�covered transactions. See below for language detertnines to award ihe covered transaction,grant,cooperative
<br /> to be used or use this form for certfication and sign. (See agreement or loan.
<br /> Append'a A of Subpart D of 43 CFR Part 12.) �
<br /> PART A: Certification Regarding Debarment,Suspension,and Other Responsibility Matters-
<br /> Primary Covered Transactions
<br /> CHECK IF THlS CERTIHCAT/ON IS FOR A PRIMARY COVERED TRANSACTfON AND IS APPUCABLE.
<br /> (1) The prospective primary pa�ticipant certifies to the best of its knowledge and belief,that it and its principals:
<br /> � {a) Are not presenty debarred,suspended,proposed for debarment,declared ineGgible,o�voluntariy exduded by any Federal
<br /> department or agency;
<br /> (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them
<br /> for commission of fraud or a criminal offense in connection witti obtaining, attempting to obtain, or performing a public
<br /> (Federal,State or local)transaction or conVact under a public transaction;violation of Federal or State antitrust statutes or
<br /> commission of embealement,theft, forgery, bribery,falsfication or destruction of records, making false statements, or
<br /> receiving stolen property;
<br /> (c) Are�ot presently in�icted for or otherwise criminally or civilly charged by a governmental entity(Federal,State or local)with
<br /> commission of any of the offenses enumerated in paragraph(1)(b)of this certification;and
<br /> (d) Have notvvitfiin a three-year period preceding this applicatioNproposal had one or more public transactions(Federal,State
<br /> or local)terminated for cause or default .
<br /> (2) Where the prospective primary participant is u�able to certify to any of the statements in this certification, such prospective
<br /> participant shall attach an explanation to this proposal.
<br /> PART B: Certification Regarding Debarment,Suspension,lneligibility and Voluntary Exclusion-
<br /> i Lower Tier Covered Transactio�s
<br /> CHECK'j�IF THIS CERTIFICATION IS FOR A LOWER T/ER COVERED TRANSACTION AND IS APPLICABLE.
<br /> (1) The prospective lower tier pa�tidpant certifies,by submission of this proposal,that neither it nor its principals is presently debarred,
<br /> suspended,proposed for debarmen�dedared ineligible,or voluntarily excluded from participation in this transaction by any Federal
<br /> department or agency.
<br /> (2) Where the prospective lowe�tier participant is unable to ceRify to any of the statements in this certification, such prospective
<br /> participant shall attach an explanation to this proposal.
<br /> � o�-zo,o
<br /> JuM 1896
<br /> (TN�form�pl�aw DI-1 Y6�,OI-1864,
<br /> OI-1Y66,DI-1Y6E�.d OI•16E31
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