AttachmentG_SuspensionDebar.pdf
PDF 108 KB Posted
- Attached to
- Washington Commodities Donation Grant Program.
- Solicitation number
- K5871
- Issued by
- Adams County, Asotin County, Benton County, Chelan County, Clallam County, Clark County, Columbia County, Cowlitz County, Douglas County, Ferry County, Franklin County, Garfield County, Grant County, Grays Harbor County, Island County, Jefferson County, King County, Kitsap County, Kittitas County, Klickitat County, Lewis County, Lincoln County, Mason County, Okanogan County, Pacific County, Pend Oreille County, Pierce County, San Juan County, Skagit County, Skamania County, Snohomish County, Spokane County, Stevens County, Thurston County, Wahkiakum County, Walla Walla County, Whatcom County, Whitman County, Yakima County, Asotin City, Clarkston City, Clarkston Heights-Vineland CDP, West Clarkston-Highland CDP, Benton City, Chelan City, Chelan Falls CDP, Clallam Bay CDP, Lewisville CDP, Rock Island City, Pacific Beach CDP, Whidbey Island Station CDP, Mercer Island City, Pacific City, Bainbridge Island City, Kingston CDP, Kitsap Lake CDP, Kittitas City, Klickitat CDP, Okanogan City, Anderson Island CDP, Fort Lewis CDP, Fox Island CDP, Herron Island CDP, Ketron Island CDP, North Fort Lewis CDP, Raft Island CDP, Stevenson City, Hat Island CDP, Lake Stevens City, Snohomish City, Spokane City, Spokane Valley City, Puget Island CDP, Garfield Town, Yakima City, Washington
About this file
This is a Suspension and Debarment Certification form from the Washington State Department of Agriculture for the Food Assistance - Washington Commodities Donation Grant Program. The document requires agencies to certify they are not currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in transactions with any federal or state department/agency.
The certification includes specific funding requirements based on the type of funding received. For state funding, a 12-digit Unique Entity ID (UEI) is not required but can be provided if available. For federal funding, a 12-digit UEI is mandatory and must be obtained through SAM.gov. The document requires the agency to certify it has not been convicted of fraud, antitrust violations, embezzlement, theft, forgery, bribery, or other criminal offenses within the past three years, and has not had any public contracts terminated for cause or default during that period.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP K5871_WashingtonCommoditiesDonation.pdf | ||
| RFPK5871_Questions_Responses.docx | DOCX document | |
| AttachmentA_Business Information.pdf | ||
| AttachmentB_EligibilityRequirements.pdf | ||
| AttachmentD_CertificationAssurances.pdf | ||
| Scoring Rubric_Final.pdf | ||
| RFPK5871_Questions_Responses121224.docx | DOCX document | |
| AttachmentC_IndentificationofCostPercent.pdf | ||
| AttachmentE_DraftWCDGPReporting.xlsx | XLSX spreadsheet | |
| AttachmentF_WashingtonCommoditiesAgreement.pdf | ||
| AttachmentG_SuspensionDebarUSE.pdf |
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Attachment A: Suspension and Debarment Certification Page 1 of 1
Washington State Department of Agriculture Food Assistance – Washington Commodities Donation Grant Program
ATTACHMENT A: SUSPENSION AND DEBARMENT CERTIFICATION
The Agency, by signature on this document, certifies that the Agency is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded in any Federal or State department or agency from participating in transactions.
The Agency certifies that it:
a. Is not presently debarred, suspended, proposed for debarment, or declared ineligible or voluntarily excluded from covered transactions by any federal or state department / agency;
b. Has not within a three-year period preceding this certification been convicted of or had a civil judgment rendered against it for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public transaction or contract (federal, state, or local); violation of federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
c. Is not presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (b) above; and
d. Has not within a three-year period preceding this certification had one or more public transactions or contracts (federal, state, or local) terminated for cause or default.
The Agency further certifies that it shall not knowingly enter into any transaction with any agency, material supplier, or vendor who is debarred, suspended, declared ineligible, or voluntarily excluded from covered transactions by any federal or state department/agency.
Please review the funding types indicated below and select the applicable funding received for this action. All forms must be signed and dated.
State funding: If State funding is provided, a 12-digit Unique Entity ID (UEI) is not required; however, if you have a UEI, please list the number. Unique Entity ID: ____________________
Federal funding: If Federal funding is provided, a 12-digit Unique Entity ID (UEI) is required. For information on how to obtain a UEI, please visit SAM.gov.
Unique Entity ID: ____________________ Expiration Date ____________________
Agency Name: ________________________________________
Contact Name: __________________________________ Title: ______________________________________
Signature: ____________________________________
Date: ____________________ https://sam.gov/content/home
| State funding If State funding is provided a 12digit Unique Entity ID UEI is not required however if you: Off |
| Agency Name: |
| Contact Name: |
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