HomeMy WebLinkAboutCertification Regarding DebarmentCERTIFICATION REGARDING DEBARMENT, SUSPENSION & OTHER
RESPONSIBILITY MATTERS
PRIMARY COVERED TRANSACTIONS
1. The applicant certifies to the best of its knowledge and belief, 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 proposal 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 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 government
entity (Federal, State, or local) with commission of any of the offenses enumerated in
paragraph 1.b of this certification; and
d. Have not within a three-year period preceding this application/proposal had one or more
public transactions (Federal, State, or local) terminated for cause or default.
Where the prospective primary participant is unable to certify to any of the statements in this
certification, such prospective participant shall submit an explanation to the City of Miami.
Applicant/
gency
Print Name of
lJ rh 6 _lr
ertifying Official
Signature of Certifying Official Date
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City of
STATE OF FLORIDA
The foregoing instrument was acknowledged before me this day of
by :1L who is personally known to me or who
(name of person whose signature is being notarized)
produced ,; as identification, and who did/did not take an oath.
(Type of Identification)
NOTARY PUBLIC:
(*natur'e) (Print Naine)
My commission expires •
SEAL
MARY T. WALLACE
MY COMMISSION ft OD 251665
EXPIRES: September 18, 2007
Bonded Thru Notary Putok Underwriters
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