TA Attachment E

Certification Regarding Debarment, Suspension, and Other Responsibility Matters –
Primary Covered Transactions

U.S. Department of Agriculture
Broadband Initiatives Program

This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 7 C.F.R. § 3017.510, Participants’ Responsibilities.
(1)

We, _______________________________________ (the Applicant) (hereinafter the
“Company”) hereby certify to the best of our knowledge and belief that neither the Company,
nor any of its principals:
(a) are presently debarred, suspended, proposed for Debarment, declared ineligible, or
voluntarily excluded from covered transactions by any Federal department or agency;
(b) have within a 3-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 commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) are 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
(d) have within a 3-year period preceding this Application had one or more public
transactions (Federal, State, or local) terminated for cause or default.

(2)

Date

If we are unable to certify to any of the statements in this certification, we shall attach an
explanation hereto.

(Authorized Representative’s Signature)
Name:
Title: