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<br />Page 21 of 23 <br />FORM 4.04 CERTIFICATE OF NON -DEBARMENT/SUSPENSION <br />REQUEST FOR PROPOSAL #2023-057 <br />PAVEMENT ASSSESSMENT <br /> <br />CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER <br />INELIGIBILITY AND VOLUNTARY EXCLUSION <br />LOWER TIER COVERED TRANSACTIONS <br /> <br />THIS FORM MUST BE COMPLETED BY THE PRIME SUPPLIER AND ANY SUB-TIER SUPPLIERS THAT WILL BE <br />AFFILIATED WITH THE WORK IN THIS QUOTE. RETURN ALL COMPLETED FORMS WITH ORIGINAL QUOTATION <br />PACKAGE. <br />The Lower Tier Participant (Applicant for a third-party subcontract or subgrant under a federal funded project), <br /> hereinafter referred to as Supplier, certifies, by submission of this <br />document, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared <br />ineligible or voluntarily excluded from participation in this transaction by any federal department or agency. <br /> <br />Where the Supplier is unable to certify to any of the statements in this certification, such Supplier must attach an <br />explanation to this submittal. <br /> <br />The Supplier, , certifies or affirms the truthfulness and accuracy of the <br />contents of the statements submitted on or with this certification and understands that the provisions of 31 <br />U.S.C. Section 3801 et seq. are applicable thereto. <br /> <br /> ________________________________________________ <br /> Signature of Authorized Official <br /> <br /> ________________________________________________ _______________________________________ <br /> Title of Authorized Official Date <br /> <br /> <br /> <br />