Voca Grant Application - New Hampshire Department Of Justice Page 14

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14
DEPARTMENT OF JUSTICE
STATE OF NEW HAMPSHIRE
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION
LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 28 CFR §67.510, Participants’ responsibilities. The intent of this
Order was to ensure that no recipient of federal funds had been restricted from conducting
business with the federal government due to any of the causes listed in 28 CFR §67.305 and
28 CFR §67.405.
By signing this document, you are certifying that neither your agency, nor its principals
are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in any transaction by any Federal department or agency.
If you are unable to sign this certification, you must attach an explanation to this
certification.
________________________________________________________________________
Name and Title of Authorized Representative
_____________________________________
_________________________
Signature
Date
________________________________________________________________________
Name and Address of Agency
Revised 10/99

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