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E MERGENCY M EDICAL S ERVICES F IRST R ESPONDER A DVANCED L IFE S UPPORT A GREEMENT (7 /1/201 9 ) <br />Page E-3 <br />EXHIBIT C - DEBARMENT AND SUSPENSION CERTIFICATION <br />1. , under penalty of perjury, certifies that, except as noted below, the City, its principal, <br />and any named subcontractor: <br />1.1 Is not currently under suspension, debarment, voluntary exclusion, or determination <br />of ineligibility by any Federal agency; <br />1.2 Has not been suspended, debarred, voluntarily excluded or determined ineligible by <br />any Federal agency within the past three years; <br />1.3 Does not have a proposed debarment pending; and, <br />1.4 Has not been indicted, convicted, or had a civil judgment rendered against it by a <br />court of competent jurisdiction in any matter involving fraud or official misconduct <br />within the past three years. <br />2.If there are any exceptions to this certification, insert the exceptions in the following space. <br />3.Exceptions shall not necessarily result in denial of award, but shall be considered in <br />determining Proposer responsibility. For any exception noted above, indicate below to <br />whom it applies, initiating agency, and dates of action. <br />4.Providing false information may result in criminal prosecution or administrative sanctions. <br />The above certification is part of the Agreement. Signing the Agreement on the signature <br />portion thereof shall also constitute signature of this Certification. <br />Name: _____________________________________ <br />Signature: _____________________________________________________________________________ <br />Title: ______________________________________ <br />Date: / / <br />685