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<br />Washington Military Department Contract Number.
<br />Debarment, Suspension, Ineligibility or Voluntary Exclusion Certification Form
<br />NAME
<br />Doing business as (DBA)
<br />CITY OF EVERETT EMERGENCY MANAGEMENT
<br />SAME
<br />ADDRESS
<br />AOpiicabtg Procurerrignt
<br />VVA' Unifariti 8usiriess
<br />Federal Employer Tax
<br />2 811 Oakes Avenue
<br />or solicitation #, ff any:
<br />identifier (1381)
<br />Identifrcation #:
<br />Everett, WA 98201
<br />313-009-341
<br />91-6001248
<br />This certification is submitted as part of a regpW to contract.
<br />Instructions For Certification Regarding De ,arriltent; .Sits.pellSion, Inoligii ility and Valtffitary Exclusion --Lower
<br />'1"ier Covered Ttatjsactions
<br />READ CAREFULLY BEFORE SiGNIttd THE CERTIFICATION. Federal regulations require contractors and bidders to sign and
<br />abide by the terms of this certification, without modification, In order to participate in certain transactions directly or
<br />indirectly involving federal funds.
<br />1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out
<br />below.
<br />2. The .certification in this clause is a material eepre'serltation of fact upon which reliance was placed when this
<br />transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an
<br />erroneous, certification, in addition to other remedies available to the Federal Government the department or agency
<br />with which this transaction originated may, ,pursue available remedies, includirâ–ºg suspension ar}dlpr de_arinent.
<br />3. The prospective lower tier participant shale provide immediate written nofiee to ftie de'. ftment,'institution or office to
<br />which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was
<br />erroneous when submitted or had become erroneous by reason of changed circumstances.
<br />4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person,
<br />primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning
<br />set,out in the Definitions and 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 regulations.
<br />5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
<br />transaction be entered into, it shall not knowingly enter into any lower tier covered transaction'with a person who is
<br />proposed for debarment under the applicable CFR, debarred, suspended, declared ineligible, or voluntarily excluded
<br />from participation in this covered transaction, unless authorized by the department or agency with which this
<br />transaction originated.
<br />6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled
<br />"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -Lower Tier Covered
<br />Transaction," without modification, in all lower 6r covered transactions and in all solicitations for lower tier covered
<br />transactions.
<br />7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
<br />transaction that it is not proposed for debarment under applicable CFR, debarred, suspended, ineligible, or voluntarily
<br />excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the
<br />method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required
<br />to, check the List of Parties Excluded from Federal Procurement and Non -procurement Programs.
<br />S. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
<br />render in good faith the certification required by this clause. The knowledge and information Qf a participant is not
<br />required to exceed that which is normally possessed by a prudent person in the ordinary course of business activity.
<br />9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction
<br />knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under applicable
<br />CFR, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other
<br />remedies available to the Federal Government, the department or agency with which this transaction originated may
<br />pursue available remedies, including suspension and/or'debarme'nt.
<br />Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion --.Lower Tier
<br />Covered Transactions
<br />The prospective lower tier participant certifies, by submission of this proposal or contract, that neither it nor its
<br />principal$ is presently debarred; suspended;, proposed for debarment, declared ineligible, or voluntarily, excluded
<br />from participation in this transaction by any Federal department or agency. Where .the prospective lower tier
<br />participant is unable to certify to any of the statements in this certification, such prospective participant shall
<br />attach an explanation to this -form.
<br />Bidder or Contractor Signature: Date:
<br />Print Name and Title: Ray Stephanson, Mayor
<br />Approved as to Form: James D. Iles, City Attorney
<br />Attest: 93 Sharon Marks, City Clerk
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