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ATTACHMENT E <br /> Debarment, Suspension, Ineligibility or Voluntary Exclusion - <br /> Certification Form <br /> Grant# E04-031 <br /> NAME Doing business as(DBA) <br /> ADDRESS Applicable Procurement WA Uniform Business Federal Employer Tax <br /> or Solicitation#,if any: Identifier(UBI) Identification#: <br /> Instructions For Certification Regarding Debarment, Suspension, Ineligibility and <br /> Voluntary Exclusion--Lower Tier Covered Transactions <br /> READ CAREFULLY BEFORE SIGNING THE CERTIFICATION. Federal regulations require <br /> contractors and bidders to sign and abide by the terms of this certification,without modification, in order <br /> to participate in certain transactions directly or indirectly involving federal funds. <br /> 1. By signing and submitting this proposal, the prospective lower tier participant is providing <br /> the certification set out below. <br /> 2. The certification in this clause is a material representation of fact upon which reliance was <br /> placed when this transaction was entered into. If it is later determined that the prospective <br /> lower tier participant knowingly rendered an erroneous certification, in addition to other <br /> remedies available to the Federal Government the department or agency with which this <br /> transaction originated may pursue available remedies, including suspension and/or <br /> debarment. <br /> 3. The prospective lower tier participant shall provide immediate written notice to the <br /> department, institution or office to which this proposal is submitted if at any time the <br /> prospective lower tier participant learns that its certification was erroneous when submitted <br /> or had become erroneous by reason of changed circumstances. <br /> 4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered <br /> transaction, participant, person, primary covered transaction, principal, proposal, and <br /> voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and <br /> Coverage sections of rules implementing Executive Order 12549. You may contact the <br /> person to which this proposal is submitted for assistance in obtaining a copy of those <br /> regulations. <br /> 5. The prospective lower tier participant agrees by submitting this proposal that, should the <br /> proposed covered transaction be entered into, it shall not knowingly enter into any lower tier <br /> 19 <br />