HomeMy WebLinkAboutAttachment 5ATTACHMENT A5
And. Voluntary Exclusion
Contractor Covered Transactions
(1) The prospective contractor of the Subrecipient, , certifies, by
submission of this document, that neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department or agency.
(2) Where the Subrecipient's contractor is unable to certify to the above statement, the prospective
contractor shall attach an explanation to this form.
CONTRACTOR:
By:
Signature Subrecipient's Name
Name and Title Department Contract Number
Street Address
City, State, Zip
Date