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ATTACHMENT I
CERTIFICATION REGARDING DEBARMENTS, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION -LOWER TIER FEDERALLY FUNDED TRANSACTIONS
DEP AGREEMENT NO: G0184
(
] . The undersigned hereby certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
2. The undersigned also certifies that it and its principals: t ,
(a) Have not within a three -year period preceding this certification 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
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performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or
State anti -trust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property.
(b) 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 2.(a) of this Certification; and
(c) Have not within a three -year period preceding this certification had one or more public transactions (Federal, State or
local) terminated for cause or default.
3. Where the undersigned is unable to certify to any of the statements in this certification, an explanation shall be attached to this
certification.
day of � t. , 20 0 l
Dated this Y
V
By
Authorized Signature /Contractor
Rocky Randels
Typed Name /Title
City of Capc Canavcral
Contractor's Firm Name
1 105 Polk Avenue
Street Address
Building, Suite Number
Cape Canaveral, FL 32920
City/State/Zip Code
(321) 868 -1240
Area Code /Telephone Number
Form DEP 55 -220 (01/01)
DEP Agreement No. G0184 Attachment I, Page 1 of 2