transaction or contract under a enumerated in paragraph (1)(b) of public transaction; violation of this certification; and Federal or State antitrust statutes or Have not within a three-year period commission of embezzlement, theft, preceding this contract had one or forgery, bribery, falsification or more public transactions (Federal, destruction of records, making false State or local) terminated for cause statements, or receiving stolen or default. property; Are not presently indicted for or the prospective contractor is unable otherwise criminally or civilly to certify to any of the statements in this charged by a governmental entity certification, such prospective contractor (Federal, State or local) with shall attach an explanation to this commission of any of the offenses proposal. CONTRACTOR SIGNATURE REQUIRED SIGNATURE OF AUTHORIZED CERTIFYING TITLE OFFICIAL Please also print or type name: ORGANIZATION NAME: (if applicable) DATE
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; 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 enumerated in paragraph (1)(b) of this certification; and Have not within a three-year period preceding this contract had one or more public transactions (Federal, State or local) terminated for cause or default. the prospective contractor is unable to certify to any of the statements in this certification, such prospective contractor shall attach an explanation to this proposal. CONTRACTOR SIGNATURE REQUIRED SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE Please also print or type name: ORGANIZATION NAME: (if applicable) DATE
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