Kernersville B-40 & South - Town of Kernersville

Contract No._11509 (WBS #: 3709.3.23; TIP #: ER-2973 I)
County: __Forsyth____________________
Rev.4-19-11
DEBARMENT CERTIFICATION
The prequalified bidder certifies to the best of his knowledge and belief, that he and his
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 of 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 statutes 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 b.
of this certification; and
d. Have not within a three-year period preceding this proposal had one or more public
transactions (Federal, State or local) terminated for cause or default.
e. Will submit a revised Debarment Certification immediately if his status changes and will show in his
bid proposal an explanation for the change in status.
If the prequalified bidder cannot certify that he is not debarred, he shall provide an explanation with this
submittal. An explanation will not necessarily result in denial of participation in a contract.
Failure to submit a non-collusion affidavit and debarment certification will result in
prequalified bidder's bid being considered non-responsive.
the
Check here if an explanation is attached to this certification.
11509; WBS #: 3709.3.23 B40 Interchange Landscape (Forsyth County) 79