Attachment E - Federal Debarment Form.docx

ATTACHMENT D

RFB No.: ILE0022

CERTIFICATION REGARDING DEBARMENT, SUSPENSION,

AND OTHER RESPONSIBILITY MATTERS

This certification is required by OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement), 2 CFR Part 180, Section 180.335, What information must I provide before entering into a covered transaction with a Federal agency?

As the duly authorized representative of the applicant, I certify, to the best of my knowledge and belief, that neither the applicant nor its principals:

· Is presently excluded or disqualified;

· Has been convicted within the preceding three years of any of the offenses listed in 2 CFR § 180.800(a) or had a civil judgment rendered against it for one of those offenses within that time period;

· Is presently indicted for, or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with, commission or any of the offenses listed in 2 CFR § 180.800(a); or

· Has had one or more public transactions (federal, state, or local) terminated within the preceding three years for cause or default.

Company/Organization Name

Name and Title of Authorized Representative

Signature Date

Unique Entity Identifier (UEI) Number

Other Notes and Instructions:

This certification is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that you 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.

You shall provide immediate written notice to the person to whom this proposal is submitted if at any time the applicant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

DWD USE ONLY

Contract No.:

rev. 5/9/22