HomeMy WebLinkAboutContractSIGNATURE AUTHORIZATION FORM
WASHINGTON STATE MILITARY DEPARTMENT
Camp Murray,Washington 98430-5122
Please read instructions on reverse side before comoleting this form.
NAME OF ORGANIZATION DATE SUBMITTED
PROJECT DESCRIPTION CONTRACT NUMBER
.
1.AUTHORIZING AUTHORITY
SIGNATURE PRINT OR TYPE NAME TITLE/TERM OF OFFICE
Armondo Pavone Mayor/2024-2028
2.AUTHORIZED TO SIGN CONTRACTS/CONTRACT AMENDMENTS
SIGNATURE PRINT OR TYPE NAME TITLE
Armondo Pavone Mayor
Ed VanValey CAO1Jf/Kristi Rowland Deputy CAO
3.AUTHORIZED TO SIGN REQUESTS FOR REIMBURSEMENT
SIGNATURE PRINT OR TYPE NAME TITLE7N,.Deborah Needham Emergency Mgmt Director
/MJ Jorgensen Emergency Mgmt Coordinator
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CITY OF RENTON
23EMPG E24-248
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SIGNATURE AUTHORIZATION FORM WASHINGTON STATE MILITARY DEPARTMENTCamp Murray, Washington 98430-5122
Please read instructions on reverse side before completing this form. NAME OF ORGANIZATION DATE SUBMITTED City of Renton 6/3/2024 PROJECT DESCRIPTION CONTRACT NUMBER 23EMPG E24-248
11.AUTHORIZING AUTHORITYSIGNATURE PRINT OR TYPE NAME TITLE/TERM OF OFFICE
ALREADY ON FILE Armando Pavone Mayor/2024-2028
2.AUTHORIZED TO SIGN CONTRACTS/CONTRACT AMENDMENTSSIGNATURE PRINT OR TYPE NAME ALREADY ON FILE Armando Pavone
ALREADY ON FILE Ed VanValey
ALREADY ON FILE Kristi Rowland
3.AUTHORIZED TO SIGN REQUESTS FOR REIMBURSEMENTSIGNATURE ALREADY ON FILE PRINT OR TYPE NAME Deborah Needham
MJ Thomas *
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TITLE
Mayor
CAO
Deputy CAO
TITLE Emergency Management Directo a Emergency Management Coordir a
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* Updated to reflect legal last name change
Washington Military Department Contract Number:_______
Debarment, Suspension, Ineligibility or Voluntary Exclusion Certification Form
NAME Doing business as (DBA)
ADDRESS Applicable Procurement
or Solicitation #, if any:
WA Uniform Business
Identifier (UBI)
Federal Employer Tax
Identification #:
This certification is submitted as part of a request to contract.
Instructions For Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower
Tier Covered Transactions
READ CAREFULLY BEFORE SIGNING THE CERTIFICATION. Federal regulations require contractors and bidders to sign and
abide by the terms of this certification, without modification, in order to participate in certain transactions directly or
indirectly involving federal funds.
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out
below.
2. The certification in this clause is a material representation of fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant 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.
3. The prospective lower tier participant shall provide immediate written notice to the department, institution or office to
which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or had become erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person,
primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning
set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the
person to which this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is
proposed for debarment under the applicable CFR, debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this covered transaction, unless authorized by the department or agency with which this
transaction originated.
6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled
``Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered
Transaction,'' without modification, in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
transaction that it is not proposed for debarment under applicable CFR, debarred, suspended, ineligible, or voluntarily
excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the
method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required
to, check the List of Parties Excluded from Federal Procurement and Non-procurement Programs.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is not
required to exceed that which is normally possessed by a prudent person in the ordinary course of business activity.
9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under applicable
CFR, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, 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.
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier
Covered Transactions
The prospective lower tier participant certifies, by submission of this proposal or contract, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency. Where the prospective lower tier
participant is unable to certify to any of the statements in this certification, such prospective participant shall
attach an explanation to this form.
Bidder or Contractor Signature: _______________________________________ Date: _____________
Print Name and Title: _______________________________________________
E24-248
City of Renton City of Renton
1055 S Grady Way, Renton, WA 98057
177-000-094 91-6001271
Kristi Rowland, Deputy Chief Administrative Office