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:DVKLQJWRQ0LOLWDU\'HSDUWPHQW&RQWUDFW1XPEHUBBBBBBBBBBBBB <br />Debarment, Suspension, Ineligibility or Voluntary Exclusion Certification Form <br />1$0( <br /> <br />'RLQJEXVLQHVVDV '%$  <br /> <br />$''5(66 <br /> <br /> <br />Applicable Procurement <br />or Solicitation #, if any: <br /> <br />:$8QLIRUP%XVLQHVV <br />,GHQWLILHU 8%,  <br /> <br />)HGHUDO(PSOR\HU7D[ <br />,GHQWLILFDWLRQ <br /> <br />This certification is submitted as part of a request to contract. <br />Instructions For Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower <br />Tier Covered Transactions <br />READ CAREFULLY BEFORE SIGNING 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 /> %\VLJQLQJDQGVXEPLWWLQJWKLVSURSRVDOWKHSURVSHFWLYHORZHUWLHUSDUWLFLSDQWLVSURYLGLQJWKHFHUWLILFDWLRQVHWRXW <br />EHORZ <br /> 7KH FHUWLILFDWLRQ LQ WKLV FODXVH LV D PDWHULDO UHSUHVHQWDWLRQ RI IDFW XSRQ ZKLFK UHOLDQFH ZDV SODFHG ZKHQ WKLV <br />WUDQVDFWLRQZDVHQWHUHGLQWR,ILWLVODWHUGHWHUPLQHGWKDWWKHSURVSHFWLYHORZHUWLHUSDUWLFLSDQWNQRZLQJO\UHQGHUHGDQ <br />HUURQHRXVFHUWLILFDWLRQLQDGGLWLRQWRRWKHUUHPHGLHVDYDLODEOHWRWKH)HGHUDO*RYHUQPHQWWKHGHSDUWPHQWRUDJHQF\ <br />ZLWKZKLFKWKLVWUDQVDFWLRQRULJLQDWHGPD\SXUVXHDYDLODEOHUHPHGLHVLQFOXGLQJVXVSHQVLRQDQGRUGHEDUPHQW <br /> 7KHSURVSHFWLYHORZHUWLHUSDUWLFLSDQWVKDOOSURYLGHLPPHGLDWHZULWWHQQRWLFHWRWKHGHSDUWPHQWLQVWLWXWLRQRURIILFHWR <br />ZKLFKWKLVSURSRVDOLVVXEPLWWHGLIDWDQ\WLPHWKHSURVSHFWLYHORZHUWLHUSDUWLFLSDQWOHDUQVWKDWLWVFHUWLILFDWLRQZDV <br />HUURQHRXVZKHQVXEPLWWHGRUKDGEHFRPHHUURQHRXVE\UHDVRQRIFKDQJHGFLUFXPVWDQFHV <br /> 7KHWHUPVFRYHUHGWUDQVDFWLRQGHEDUUHGVXVSHQGHGLQHOLJLEOHORZHUWLHUFRYHUHGWUDQVDFWLRQSDUWLFLSDQWSHUVRQ <br />SULPDU\FRYHUHGWUDQVDFWLRQSULQFLSDOSURSRVDODQGYROXQWDULO\H[FOXGHGDVXVHGLQWKLVFODXVHKDYHWKHPHDQLQJ <br />VHWRXWLQWKH'HILQLWLRQVDQG&RYHUDJHVHFWLRQVRIUXOHVLPSOHPHQWLQJ([HFXWLYH2UGHU<RXPD\FRQWDFWWKH <br />SHUVRQWRZKLFKWKLVSURSRVDOLVVXEPLWWHGIRUDVVLVWDQFHLQREWDLQLQJDFRS\RIWKRVHUHJXODWLRQV <br /> 7KH SURVSHFWLYH ORZHU WLHU SDUWLFLSDQW DJUHHV E\ VXEPLWWLQJWKLV SURSRVDO WKDW VKRXOG WKH SURSRVHG FRYHUHG <br />WUDQVDFWLRQEHHQWHUHGLQWRLWVKDOOQRWNQRZLQJO\HQWHULQWRDQ\ORZHUWLHUFRYHUHGWUDQVDFWLRQZLWKDSHUVRQZKRLV <br />SURSRVHGIRUGHEDUPHQWXQGHUWKHDSSOLFDEOH&)5GHEDUUHGVXVSHQGHGGHFODUHGLQHOLJLEOHRUYROXQWDULO\H[FOXGHG <br />IURP SDUWLFLSDWLRQ LQ WKLV FRYHUHG WUDQVDFWLRQ XQOHVV DXWKRUL]HG E\ WKH GHSDUWPHQW RU DJHQF\ ZLWK ZKLFK WKLV <br />WUDQVDFWLRQRULJLQDWHG <br /> 7KHSURVSHFWLYHORZHUWLHUSDUWLFLSDQWIXUWKHUDJUHHVE\VXEPLWWLQJWKLVSURSRVDOWKDWLWZLOOLQFOXGHWKLVFODXVHWLWOHG <br />CC&HUWLILFDWLRQ 5HJDUGLQJ 'HEDUPHQW 6XVSHQVLRQ ,QHOLJLELOLW\DQG 9ROXQWDU\ ([FOXVLRQ/RZHU 7LHU &RYHUHG <br />7UDQVDFWLRQ<br /><br />ZLWKRXWPRGLILFDWLRQLQDOOORZHUWLHUFRYHUHGWUDQVDFWLRQVDQGLQDOOVROLFLWDWLRQVIRUORZHUWLHUFRYHUHG <br />WUDQVDFWLRQV <br /> $SDUWLFLSDQWLQDFRYHUHGWUDQVDFWLRQPD\UHO\XSRQDFHUWLILFDWLRQRIDSURVSHFWLYHSDUWLFLSDQWLQDORZHUWLHUFRYHUHG <br />WUDQVDFWLRQWKDWLWLVQRWSURSRVHGIRUGHEDUPHQWXQGHUDSSOLFDEOH&)5GHEDUUHGVXVSHQGHGLQHOLJLEOHRUYROXQWDULO\ <br />H[FOXGHGIURPFRYHUHGWUDQVDFWLRQVXQOHVVLWNQRZVWKDWWKHFHUWLILFDWLRQLVHUURQHRXV$SDUWLFLSDQWPD\GHFLGHWKH <br />PHWKRGDQGIUHTXHQF\E\ZKLFKLWGHWHUPLQHVWKHHOLJLELOLW\RILWVSULQFLSDOV(DFKSDUWLFLSDQWPD\EXWLVQRWUHTXLUHG <br />WRFKHFNWKH/LVWRI3DUWLHV([FOXGHGIURP)HGHUDO3URFXUHPHQWDQG1RQSURFXUHPHQW3URJUDPV <br /> 1RWKLQJFRQWDLQHGLQWKHIRUHJRLQJVKDOOEHFRQVWUXHGWRUHTXLUHHVWDEOLVKPHQWRIDV\VWHPRIUHFRUGVLQRUGHUWR <br />UHQGHULQJRRGIDLWKWKHFHUWLILFDWLRQUHTXLUHGE\WKLVFODXVH7KHNQRZOHGJHDQGLQIRUPDWLRQRIDSDUWLFLSDQWLVQRW <br />UHTXLUHGWRH[FHHGWKDWZKLFKLVQRUPDOO\SRVVHVVHGE\DSUXGHQWSHUVRQLQWKHRUGLQDU\FRXUVHRIEXVLQHVVDFWLYLW\ <br /> ([FHSWIRUWUDQVDFWLRQVDXWKRUL]HGXQGHUSDUDJUDSKRIWKHVHLQVWUXFWLRQVLIDSDUWLFLSDQWLQDFRYHUHGWUDQVDFWLRQ <br />NQRZLQJO\HQWHUVLQWRDORZHUWLHUFRYHUHGWUDQVDFWLRQZLWKDSHUVRQZKRLVSURSRVHGIRUGHEDUPHQWXQGHUDSSOLFDEOH <br />&)5VXVSHQGHGGHEDUUHGLQHOLJLEOHRUYROXQWDULO\H[FOXGHGIURPSDUWLFLSDWLRQLQWKLVWUDQVDFWLRQLQDGGLWLRQWRRWKHU <br />UHPHGLHVDYDLODEOHWRWKH)HGHUDO*RYHUQPHQWWKHGHSDUWPHQWRUDJHQF\ZLWKZKLFKWKLVWUDQVDFWLRQRULJLQDWHGPD\ <br />SXUVXHDYDLODEOHUHPHGLHVLQFOXGLQJVXVSHQVLRQDQGRUGHEDUPHQW <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 />principals 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 />%LGGHURU&RQWUDFWRU6LJQDWXUHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 'DWHBBBBBBBBBBBBB <br />3ULQW1DPHDQG7LWOHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB <br />D17-1016 <br />County of Kittitas <br />Kittitas County <br />205 West 5th Avenue, Suite 105 <br />Ellensburg WA 98926 192002673 91-60019349 <br />December 5, 2017 <br />Judy Pless <br />Budget Finance Officer