Debarment Statement Form. This is a Washington form and can be use in Department Of Social And Health Services Statewide.
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DEBARMENT STATEMENT SECTION ONE FREQUENTLY ASKED QUESTIONS ABOUT DEBARMENT What is “Debarment, Suspension, Ineligibility, and Voluntary Exclusion”? These terms refer to the status of a person that cannot contract with or receive grants from a federal agency. In order to be debarred, suspended, ineligible, or voluntarily excluded, you must: • Have had a contract or grant with a federal agency, and • Have gone through some process where the federal agency notified or attempted to notify you that you could not contract with the federal agency • Generally, this process occurs where you, the contractor, are not qualified or are not adequately performing under a contract, or have violated a regulation or law pertaining to the contract. Why am I required to sign this certification? You are requesting a contract or grant with DSHS. Federal law (Executive Order 12549) requires DSHS to ensure that persons or companies that contract with DSHS are not prohibited from having federal contracts. What is Executive Order 12549? Executive Order 12549 refers to Federal Executive Order Number 12549. The executive order was signed by the President of the United States and directed federal agencies to ensure that federal agencies, and any state or other agency receiving federal funds were not contracting or awarding grants to persons, organizations, or companies who have been excluded from participating in federal contracts or grants. What does the word “proposal” mean when referred to in this certification? Proposal means a solicited or unsolicited bid, application, request, invitation to consider or similar communication from you to DSHS. What or who is “lower tier participant”? Lower tier participant means a person or organization that submits a proposal, enters into contracts with, or receives a grant from DSHS, OR any subcontractor of a contract with DSHS. If you hire subcontractors, you should require them to sign a certification and keep it with your subcontract. What is a covered transaction when referred to in this certification? Covered Transaction means a contract, oral or written agreement, grant, or any other arrangement where you contract with or received money from DSHS. Covered Transaction does not include mandatory entitlements and individual benefits. American LegalNet, Inc. www.FormsWorkFlow.com DEBARMENT STATEMENT SECTION TWO NPI NAME DOING BUSINESS AS (DBA) FEIN/SSN This certification is submitted as part of a request to contract. The applicable Procurement or Solicitation Number, if any, is Instructions For Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion- -Lower Tier Covered Transactions READ CAREFULLY BEFORE SIGNING THE CERTIFICATION. Federal regulations require contractors and bidders to sign and abide by the terms of this certification, without modification, in order to participate in certain transactions directly or indirectly involving federal funds. 1. 2. 3. 4. 5. 6. 7. 8. 9. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal and voluntarily excluded as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a coy of those regulations. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, I shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CRF part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion- -Lower Tier Covered Transaction,” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. A participant in a covered transition may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the LIST of Parties Excluded from Federal Procurement and Nonprocurement Programs. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion- - Lower Tier Covered Transactions 1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared in eligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. BIDDER OR CONTRACTOR SIGNATURE DATE PRINT NAME AND TITLE American LegalNet, Inc. www.FormsWorkFlow.com