2005/01/12 Council Agenda Packet

S:\GLarson\WORD\PSA Survey 2005-2006.doc 3 Exhibit D-2 Certification Regarding Debarment, Suspension, and Other Responsibility Matters-Primary Covered Transactions 1. The prospective primary participant certifies to the best of its knowledge and belief,that it and its principals: (a) Are not presently debarred, suspended,proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission or fraud or a criminal offense in connection with obtaining, attempting to obtain,or performing a public(federal, state,or local)transaction or contract under a public transaction; violation of federal or state antitrust statues or commission of embezzlement,theft, forgery,bribery, falsification or destruction of records,making false statements,or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state,or local)with commission of any of the offenses enumerated in paragraph Lb. of this certification; and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions (federal,state, or local)terminated for cause or default. 2. Where the prospective primary participant is unable to certify to any of the statements in this certification,such prospective participant shall attach an explanation to this proposal. Consultant: (Firm): Date Signature 18