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Federal Debarment Form - Certification Regarding Debarment, Suspension, Ineligibility And Voluntary Exclusion - Montana Department Of Administration

STATE OF MONTANA

DEPARTMENT OF ADMINISTRATION

ARCHITECTURE AND ENGINEERING DIVISION

1520 East Sixth Avenue • P.O. Box 200103 • Helena, Montana 59620.0103

Phone: 406.444.3104 • Fax: 406.444.3399

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

INELIGIBILITY AND VOLUNTARY EXCLUSION

Project Name:

Location:

A/E #:

THIS DEBARMENT FORM MUST BE SIGNED AND SUBMITTED ALONG WITH THE PROPOSAL.

TO:

DEPARTMENT OF ADMINISTRATION

ARCHITECTURE AND ENGINEERING DIVISION

1520 EAST SIXTH AVENUE,

P.O. BOX 200103

HELENA, MT 59620-0103

This certification is required by the regulations implementing Executive Order 12549, Debarment and

Suspension, 43 CFR Part 12, Section 12.510, Participants' Responsibilities. The regulations were published as

Part VII of the May 26, 1988 Federal Register (pages 19160-19211). For further assistance in obtaining a copy

of the regulations, contact the U.S. General Services Administration.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS)

(1) The prospective lower tier participant certifies, by submission of this proposal 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 of agency.

(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification,

such prospective participant shall attach an explanation to this proposal.

Company

Name and Title of Authorized Representative

Signature

Date

s:\boilerplate\Federal_Debarment_Form.doc

FEDERAL DEBARMENT FORM (02-01-99)

Federal Debarment Form - Certification Regarding Debarment, Suspension, Ineligibility And Voluntary Exclusion - Montana Department Of Administration