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Enclosure <br /> <br />U.S. DEPARTMENT OF AGRICULTURE <br /> <br />Certification Regarding Debarment, Suspension, and Other <br />Responsibility Matters - Primary Covered Transactions <br /> <br />This certification is required by the regulations implementing Executive Order 12549, Debarment and <br />Suspension, 7 CFR Part 3017, Section 3017.510, P ' ' · .... <br />art~c~pants responmbtht~es. The regulations were published <br />as Part IV of the January 30, 1989, Federal Register (pages 4722-4733). Copies of the regulations may be <br />obtained by contacting the Department of Agriculture agency offering the proposed covered transaction. <br /> <br /> (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE) <br /> <br /> (1) The prospective primary participant certifies to the best of its knowledge and belief, that it and <br /> its principals: <br /> <br /> (a)are n°t presently debarred, suspended, proposed for debarment, declared ineligible,or <br /> voluntarily excluded from covered transactions by any Federal department or agency; <br /> (b) have n°t within a three-year period preceding this proposal been convicted of or had <br /> ~ civil judgment rendered against them for commission of fraud or a criminal offense <br /> m connection with obtaining, attempting to obtain, or performing a public (Federal <br /> State or lecal) transaction or contract under a public transaction; violation of Fed- <br /> eral or State antitrust statutes or commission of embezzlement, theft, forgery, bibery, <br /> falsification or destruction of records, making false statements, or receiving stolen <br /> property; <br /> <br /> (c) are not presently indicted for or otherwise criminally or civilly charged by a <br /> governmental entity (Federal, State or local) with commission of any of the offenses <br /> enumerated in paragraph (l)(b) of this certification; and <br /> <br /> (d) have not within a three-year period preceding this application/proposal had one or <br /> more public transactions (Federal, State or local) terminated for cause or default. <br /> <br />(2) Where the prospective primary participant is unable to certify to any of the statements in this <br /> certification, such prospective participant shall attach an explanation to this proposal. <br /> <br />City of Martinsville <br /> <br />West Church Street Commercial Corridor Revita]izati¢ <br /> <br />Organization Name <br /> <br />PR/Award Number or Project Name <br /> <br />W. W. Bartlett, Interim City Manager <br /> <br />Name(s) and ~itle(s) of Authorized Rep~sentative(s) <br /> <br />Signature(s) <br /> <br />February 24, 2004 <br /> <br />Form AD-1047 (1/92) <br /> <br /> <br />