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STATE OF WASHINGTON <br />DEPARTMENT OF COMMERCE <br />JUSTICE ASSISTANCE GRANT <br />FORM 2 <br />U.S. DEPARTMENT OF JUSTICE <br />OFFICE OF JUSTICE PROGRAMS <br />OFFICE OF THE COMPTROLLER <br />CERTIFICATION REGARDING <br />DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION <br />LOWER TIER COVERED TRANSACTIONS <br />(SUB -RECIPIENT) <br />This certification is required by the regulations implementing Executive Order 12549, Debarment and <br />Suspension, 28 CFR Part 67, Section 67.510, Participants' responsibilities. The regulations were <br />published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211). <br />(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE) <br />(1) The prospective lower tier participant certifies by submission of this proposal that neither it nor its <br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or <br />voluntarily excluded from participation in this transaction by any Federal department or agency. <br />(2) Where the prospective lower tier participant is unable to certify to any of the statements in this <br />certification, such prospective participant shall attach an explanation to this proposal. <br />Name and Title of Authorized Representative <br />Signature Date <br />Name of Organization <br />Address of Organization <br />7 <br />