18-10 Contract

APPLICATION FOR ESSEX COUNTY DIVISION ON AGING GRANT CERTIFICATION REGARDING DEBARMENT AND SUSPENSION In accordance to Federa] Executive Order 12549, “Debarment and Suspension,” the undersigned certifies, to the best of his or her knowledge that as an applicant, this agency or its key employees: a. are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal Department or agency, or by the State of New Jersey: have not within a 3-year period preceding this application been convicted of or had a civil judgement 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 statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; are not presently indicted or for otherwise criminally or civilly charged by a gover- mental entity (Federal, State, or Local) with commission of any offenses enumerated in paragraph (b) of this certification; and d. have not within a 3-year period preceding this application had one or more public transactions (Federal, State, or Local) terminated for cause of default. The applicant agrees that by submitting this application, it will obtain from all its sub- grantees a certification that includes without modification paragraphs (a), (b), (c), (d), of this certification in accordance with Federal Executive Order 12549. NAME OF AGENCY Township of West Orange NAME AND TITLE OF OFFICIAL SIGNING FOR AGENCY Joseph A. Fonzino, Director/Health Officer SIGNATURE_OF ABO DATE SIGNED 01/07/10 ij NOTE: ‘oll Ed related to Debarment and Suspension as required by Federal regulations Will be used as the basis for completion of this certification: List of parties excluded from Federal Procurement of Non-Procurement Programs. This document is distributed by U.S. General Services Adminstration. U.S. Printing Office. Washington D.C. This document can be acquired from the Superintendent of Documents.