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public transaction; violation of Federal or <br />State antitrust statutes or commission of <br />embezzlement, theft, forgery, bribery, <br />falsification or destruction of records, <br />making false statements, or receiving <br />stolen property; <br />c) Are not presently indicted for or <br />otherwise criminally or civilly charged by <br />a governmental entity (Federal, State or <br />local) with commission of any of the <br />offenses enumerated in paragraph (1)(b) <br />of this certification; and <br />d) Have not within a three-year period <br />preceding this contract had one or more <br />public transactions (Federal, State or <br />local) terminated for cause or default. <br />2) Where the prospective contractor is unable to <br />certify to any of the statements in this <br />certification, such prospective contractor <br />shall attach an explanation to this proposal. <br />CONTRACTOR SIGNATURE REQUIRED <br />SIGNATURE OF AUTHORIZED CERTIFYING <br />OFFICIAL <br />TITLE <br />Please also print or type name: <br />ORGANIZATION NAME: (if applicable) <br />DATE <br />Local Health Jurisdiction Page 41 of 59 Medicaid Administrative Claiming <br />Washington State Health Care Authority Contract # K3069 <br />