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U.S. DEPARTMENT OF AGRICULTURE Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions This certification is required by the regulations implementing Executive Order 12549, Debarment end Suspension, 7 CFR Pert 3017, Section 3017.510, Participants' responsibilities. The regulations were published as Part [V of the January 30, 1989, Federal Resister (pages 4722.4733). Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the proposed covered transaction. (BEFORE CONPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE) (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 voLuntari ly 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 ui th 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) ere 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 (1)(b) 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) Yhere 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. County of Hawaii Rural Housing Preservation Grant Organization Neme PR/Award Number or Project Name Stephen K. Yamashiro, Mavor Name and Title of Authorized Representative Signature Date 1 Form AD~1047 (2/89)