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DocuSign Envelope ID: 4166FC64-6496-4305-B555-38A 17 4BDAA73 <br />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 TITLE <br />FtCr <br />DATE <br />Local Health Jurisdiction Page 41 of59 <br />Washington State Health Care Authority <br />J:7-ll <br />Medicaid Administrative Claiming <br />Contract # K3069