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ATTACHMENT 290.4

OPRPM Form 94

(Rev. 07/03)

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT,

AND OTHER RESPONSIBILITY MATTERS (MAY 1989)

The Offeror certifies, to the best of its knowledge and

(b) The Offeror shall provide immediate written

belief, that--

notice to the Contracting Officer if, at any time prior to

contract award, the Offeror learns that its certification

(a)

The Offeror and/or any of its Principals--

was erroneous when submitted or has become

erroneous by reason of changed circumstances.

(i) Are

are not

presently debarred,

suspended, proposed for debarment, or declared

(c)

A certification that any of the items in

ineligible for the award of contracts by any

paragraph (a) of this provision exists will not necessarily

Federal agency;

result in withholding of an award under this solicitation.

However, the certification will be considered in

(ii) Have

have not

, within a three-

connection with a determination of the Offeror's

year period preceding this offer, been convicted

responsibility.

Failure of the Offeror to furnish a

of or had a civil judgment rendered against them

certification or provide such additional information as

for: commission of fraud or a criminal offense in

requested by the Contracting Officer may render the

connection with obtaining, attempting to obtain, or

Offeror nonresponsible.

performing a public

(Federal, state, or local)

contract or subcontract; violation of Federal or

(d) Nothing contained in the foregoing shall be

state antitrust statutes relating to the submission

construed to require establishment of a system of

of offers; or commission of embezzlement, theft,

records in order to render, in good faith, the certification

forgery, bribery, falsification or destruction of

required by paragraph (a) of this provision.

The

records, making false statements, or receiving

knowledge and information of an Offeror is not required

stolen property; and

to exceed that which is normally possessed by a

prudent person in the ordinary course of business

(iii) Are

are not

presently indicted

dealings.

for, or otherwise criminally or civilly charged by a

governmental entity with, commission of any of

(e) The certification in paragraph (a) of this

the offenses enumerated in subdivision (ii) above.

provision is a material representation of fact upon which

reliance was placed when making award. If it is later

(iv) The Offeror has

has not

determined that the Offeror knowingly rendered an

within a three-year period preceding this offer,

erroneous certification, in addition to other remedies

had one or more contracts terminated for default

available to the Government, the Contracting Officer

by any Federal agency.

may terminate the contract resulting from this

solicitation for default.

"Principals," for the purposes of this certification,

means officers; directors; owners; partners; and,

persons having primary management or supervisory

____________________________________________

responsibilities within a business entity (e.g., general

Signature

Date

manager; plant manager; head of a subsidiary, division,

or business segment, and similar positions).

____________________________________________

Title

THIS CERTIFICATION CONCERNS A MATTER

WITHIN THE JURISDICTION OF AN AGENCY OF

____________________________________________

THE UNITED STATES AND THE MAKING OF A

Company

FALSE,

FICTITIOUS,

FRAUDULENT

CERTIFICATION

MAY

RENDER

THE

MAKER

SUBJECT

PROSECUTION

UNDER

SECTION 1001, TITLE 18, UNITED STATES CODE.

Oprpm Form 94 - Certification Regarding Debarment, Suspension, Proposed Debarment, And Other Responsibility Matters (May 1989)

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