Loading...
Washington State Military Department ILA for All Hazards Alert Broadcast (AHAB) Siren Agreement Face SheetIP hvc 1S94 No. (City Clerk Use Only) CONTRACT ROUTING FORM Z Originator: Charles Wallace O H Department/Division: Human Resources a Fe Name of Consultant/Contractor: WA State Military Department WCONTRACT TITLE: All Hazards Alert Broadcast (/ G Routed by: Date: �HAB) Siren Agreement Face Sheet Type of Contract: ® (GR) Grants Q (1) Intergovernmental Agreement ® (L) Lease Agreement Z Z (S) Purchase of Services 0 (W) Public Works a(0) Other W � Project/Bid/RFP No: Z L) Effective Date: September 01, 2021 Has the original contract boilerplate language been modified? If yes, specify which sections have been modified: pDescription V I of Services: Total Amount of Contract: Date: August 31, 2031 Amount: Amount: y Budget # Budget # J_ Q Amount: Amount: w Budget # Budget # C QBudget # Amount: Budget # Amount: V QAre there sufficient funds in the current budget to cover this contract? Yes No Z Remarks: � City is responsible for power to the siren. City is responsible for replacement back-up power batteries (8 car batteries, approximately every 3-5 years) Authorization Level: w ❑ 1. Project Manager Q ❑ 2. Risk Management/Budget Z ❑ 3. City Attorney 23 ❑ 4. Consultant/Contractor U ❑ 5.Other ❑ 6. City Council Approval ❑ Date (if applicable) ❑ 7. Mayor ❑ 8. City Clerk Washington State Military Department ALL HAZARDS ALERT BROADCAST (AHAB) SIREN AGREEMENT FACE SHEET 1. Recipient Name and Address 2. UBI # (state revenue). 3. Agreement Number: City of Edmonds E22-168 Revised 121 5th Ave N 312-000-093 Edmonds, WA 98020 4. Recipient Contact, phone/email: 5. Agreement Start Date 6. Agreement End Date: Charles Wallace, 425-771-0277 x4203 September 1, 2021 August 31, 2031 Charles.Wallace edmondswa. ov 7. Department Contact, phone/email: 8. Data Universal Numbering System (DUNS) Maximilian Dixon, (253) 512-7017 040172827 Maximilian.Dixon mil.wa. ov 9. Service Districts: 10. EIN (BY LEGISLATIVE DISTRICT): 21 91-6001244 (BY CONGRESSIONAL DISTRICT): 7 9. Agreement Classification 10. Contract Type (check all that apply): ❑ Personal Services ❑ Client Services ❑ Contract X Agreement X Public/Local Gov't ❑ Intergovernmental (RCW 39.34) ❑ Research/Development ❑ A/E ❑ Other ❑ Interagency 11. PURPOSE & DESCRIPTION: The Washington Military Department (Department) has authority to enter into this Agreement pursuant to RCW 38.52.010, RCW 38.52.020, and RCW 38.52.030, which statutes direct and authorize the Department to prepare for, mitigate, and respond to emergencies and disasters. The Department through the Earthquake/Tsunami Program provides public awareness and education regarding preparing for, and surviving, a natural or man-made disaster event. The Department would, with this agreement pay for not only the cost to purchase and install All Hazards Alert Broadcast (AHAB) Warning Sirens that provide both tone and voice alert capability for all -hazards, but would be responsible for, leasing space, installation, regular maintenance requirements, operation, and testing of the sirens. With this agreement, the Department agrees to install AHAB siren(s) on Recipient's land at no cost to the Department, with location(s) to be identified within the Statement of Work (Attachment C). Once the AHAB siren(s) are installed, they become property of Recipient. In consideration of receipt of the siren(s) for protection of people in the County, Recipient agrees to be responsible for all operation and to maintain the siren(s) in full compliance with Department's maintenance requirements according to Department guidance and as set out in the Statement of Work (Attachment C). IN WITNESS WHEREOF, In consideration of the mutual covenants and promises contained below, the receipt and sufficiency of which is acknowledged by each of the parties, and without payment of money for the privileges granted, the Department and Recipient agree as follows: the Department and Recipient acknowledge and accept the terms of this Agreement, including all referenced Attachments which are hereby incorporated in and made a part hereof, agree that the consideration is sufficient, and have executed this Agreement as of the date below. This Agreement Face Sheet; Special Terms & Conditions (Attachment A); General Terms and Conditions (Attachment B); Statement of Work (Attachment C); AHAB Site Survey Information Template (Attachment D), and all other documents and attachments expressly referenced and incorporated herein contain all the terms and conditions agreed upon by the parties and govern the rights and obligations of the parties to this Agreement. No other understandings, oral or otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to bind any of the parties hereto. In the event of an inconsistency in this Agreement, unless otherwise provided herein, the inconsistency shall be resolved by giving precedence in the following order: 1. Applicable Federal and State Statutes and Regulations 4. Special Terms and Conditions 2. General Terms and Conditions 5. Other provisions of the Agreement incorporated by reference 3. Statement of Work WHEREAS, the parties hereto have executed this Agreement on the day and year last sp.cified below. F E DEPA MENT: FORTH RECIP NT: 1 /17/2023 ft Sign t e V Date Siga6ture Date Regan Anne Hesse, Chief Financial Officer Mike Nelson, Mayor Washington State Military Department Scott Passey, City Clerk APPROVED AS TO FORM APPROVED AS TO FORM (if applicable): Dawn C. Cortez 10/08/202001/05/2023 Assistant Attorney General Applicant's Legal Review Date ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 1 of 11 City of Edmonds, E22-168 Revised Attachment B Washington State Military Department GENERAL TERMS AND CONDITIONS DEFINITIONS As used throughout this Agreement, the terms will have the same meaning as defined in 2 CFR 200 Subpart A (which is incorporated herein by reference), except as otherwise set forth below: a. "Agreement" means this Agreement. b. "Siren(s)" means the All Hazards Alert Broadcast (AHAB) Warning Siren; a physical, pole - mounted, modular siren system that alerts those within range to danger by emitting a voice, tone, and intense blue light alert. C. "Department' means the Washington State Military Department, as a state agency, any division, section, office, unit or other entity of the Department, or any of the officers or other officials lawfully representing that Department. The Department is a Recipient of a federal award directly from a federal awarding agency and is the pass -through entity making a subaward to a Recipient under this Agreement. d. "Recipient' means the entity identified on the Face Sheet of this Agreement. e. "Monitoring Activities" means all administrative, financial, or other review activities that are conducted to ensure compliance with all state and federal laws, rules, regulations, authorities and policies. 2. AMENDMENTS AND MODIFICATIONS The Recipient or the Department may request, in writing, an amendment or modification of this Agreement. However, such amendment or modification shall not be binding, take effect or be incorporated herein until made in writing and signed by the authorized representatives of the Department and the Recipient. No other understandings or agreements, written or oral, shall be binding on the parties. 3. AMERICANS WITH DISABILITIES ACT ADA OF 1990. PUBLIC LAW 101-336 42 U.S.C. 12101 ET SEQ. AND ITS IMPLEMENTING REGULATIONS ALSO REFERRED TO AS THE "ADA" 28 CFR Part 35. The Recipient must comply with the ADA, which provides comprehensive civil rights protection to individuals with disabilities in the areas of employment, public accommodations, state and local government services, and telecommunication. 4. ASSURANCES The Department and the Recipient agree that all activity pursuant to this Agreement will be in accordance with all the applicable current federal, state and local laws, rules and regulations. 5. CERTIFICATION REGARDING DEBARMENT. SUSPENSION OR INELIGIBILITY As federal funds are a basis for this Agreement, the Recipient certifies that the Recipient is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this Agreement by any federal department or agency. The Recipient shall complete, sign, and return a Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion form located at httr)://mil.wa.gov/emergency-mana ement- division/agreements/recluiredagreementforms. Any such form completed by the Recipient for this Agreement shall be incorporated into this Agreement by reference. 6. CONFLICT OF INTEREST No officer or employee of the Department; no member, officer, or employee of the Recipient or its designees or agents; no member of the governing body of the jurisdiction in which the project is undertaken or located; and no other official of the Recipient who exercises any functions or responsibilities with respect to the project during his or her tenure, shall have any personal or pecuniary gain or interest, direct or indirect, in any contract, subcontract, or the proceeds thereof, for work to be performed in connection with the project assisted under this Agreement. 7. COMPLIANCE WITH APPLICABLE STATUTES RULES AND DEPARTMENT POLICIES The Recipient shall comply with, and the Department is not responsible for determining, compliance with, any and all applicable federal, state, and local laws, regulations, executive orders, OMB Circulars, and/or policies. This obligation includes, but is not limited to: nondiscrimination laws and/or policies, Energy Policy and Conservation Act (PL 94-163, as amended), the Americans with Disabilities Act ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 3 of 11 City of Edmonds, E22-168 Revised fees for any claims or action commenced thereon arising out of or in connection with that party's acts or activities authorized by this Agreement. This obligation shall not include such claims, costs, damages or expenses which may be caused by the sole negligence of one of the parties; provided, that if the claims or damages are caused by or result from the concurrent negligence of (1) the Department, and (2) the Recipient, its agents, or employees, this indemnity provision shall be valid and enforceable only to the extent of the negligence of the Recipient, or Recipient's agents or employees. 11. LIMITATION OF AUTHORITY — AUTHORIZED SIGNATURE The signatories to this Agreement represent that they have the authority to bind their respective organizations to this Agreement. Only the Department's Authorized Signature representative and the Authorized Signature representative of the Recipient or Alternate for the Recipient, formally designated in writing, shall have the express, implied, or apparent authority to alter, amend, modify, or waive any clause or condition of this Agreement. Any alteration, amendment, modification, or waiver of any clause or condition of this Agreement is not effective or binding unless made in writing and signed by both parties' Authorized Signature representatives. Further, only the Authorized Signature representative or Alternate for the Recipient shall have signature authority to sign time extension requests, amendment and modification requests, requests for changes to projects or work plans, and other requests, certifications and documents authorized by or required under this Agreement. 12. NONASSIGNABILITY Neither this Agreement, nor any claim arising under this Agreement, shall be transferred or assigned by the Recipient. 13. NONDISCRIMINATION The Recipient shall comply with all applicable federal and state non-discrimination laws, regulations, and policies. No person shall, on the grounds of age, race, creed, color, sex, sexual orientation, religion, national origin, marital status, honorably discharged veteran or military status, or disability (physical, mental, or sensory) be denied the benefits of, or otherwise be subjected to discrimination under any project, program, or activity, funded, in whole or in part, under this Agreement. 14. NOTICES The Recipient shall comply with all public notices or notices to individuals required by applicable local, state and federal laws and regulations and shall maintain a record of this compliance. 15.000UPATIONAL SAFETY/HEALTH ACT and WASHINGTON INDUSTRIAL SAFETYI HEALTH ACT (OSHAIWISHA} The Recipient represents and warrants that its workplace does now or will meet all applicable federal and state safety and health regulations that are in effect during the Recipient's performance under this Agreement. To the extent allowed by law, the Recipient further agrees to indemnify and hold harmless the Department and its employees and agents from all liability, damages and costs of any nature, including, but not limited to, costs of suits and attorneys' fees assessed against the Department, as a result of the failure of the Recipient to so comply. 16.OWNERSHIP OF PROJECTICAPITAL FACILITIES The Department makes no claim to any capital facilities or real property improved or constructed with funds under this Agreement and does not and will not acquire any ownership interest or title to such property of the Recipient. The Recipient shall assume all liabilities and responsibilities arising from the ownership and operation of the project and agrees to indemnify and hold the Department, the state of Washington harmless from any and all causes of action arising from the Recipient's ownership and operation of the project. 17. PUBLICITY The Parties agrees to submit to each other, prior to issuance, all advertising and publicity matters relating to this Agreement wherein the other Party's name is mentioned, or language used from which the connection of the other Party's name may be inferred or implied. The Parties agree not to publish or use such advertising and publicity matters without the prior written consent of the other Party. ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 5 of 11 City of Edmonds, E22-168 Revised The Department may notify the Recipient in writing of the need to take corrective action and provide a period of time in which to cure. The Department is not required to allow the Recipient an opportunity to cure if it is not feasible as determined solely within the Department's discretion. Any time allowed for cure shall not diminish or eliminate the Recipient's liability for damages or otherwise affect any other remedies available to the Department. If the Department allows the Recipient an opportunity to cure, the Department shall notify the Recipient in writing of the need to take corrective action. If the corrective action is not taken within ten (10) calendar days or as otherwise specified by the Department, or if such corrective action is deemed by the Department to be insufficient, the Agreement may be terminated in whole or in part. The Department reserves the right to suspend all or part of the Agreement, withhold further payments, or prohibit the Recipient from incurring additional obligations of funds during investigation of the alleged compliance breach, pending corrective action by the Recipient, if allowed, or pending a decision by the Department to terminate the Agreement in whole or in part. In the event of termination, the Recipient shall be liable for all damages as authorized by law, including, but not limited to, any cost difference between the original Agreement and the replacement or cover Agreement and all administrative costs directly related to the replacement Agreement, e.g., cost of administering the competitive solicitation process, mailing, advertising and other associated staff time. The rights and remedies of the Department provided for in this section shall not be exclusive and are in addition to any other rights and remedies provided by law. If it is determined that the Recipient: (1) was not in default or material breach, or (2) failure to perform was outside of the Recipient's control, fault or negligence, the termination shall be deemed to be a "Termination for Convenience". 24. TERMINATION PROCEDURES In addition to the procedures set forth below, if the Department terminates this Agreement, the Recipient shall follow any procedures specified in the termination notice. Upon termination of this Agreement and in addition to any other rights provided in this Agreement, the Department may require the Recipient to deliver to the Department any property specifically produced or acquired for the performance of such part of this Agreement as has been terminated. If the termination is for convenience, the Department shall pay to the Recipient as an agreed upon price, if separately stated, for properly authorized and completed work and services rendered or goods delivered to and accepted by the Department prior to the effective date of Agreement termination, the amount agreed upon by the Recipient and the Department for (i) completed work and services and/or equipment or supplies provided for which no separate price is stated, (ii) partially completed work and services and/or equipment or supplies provided which are accepted by the Department, (iii) other work, services and/or equipment or supplies which are accepted by the Department, and (iv) the protection and preservation of property. Failure to agree with such amounts shall be a dispute within the meaning of the "Disputes" clause of this Agreement. If the termination is for cause, the Department shall determine the extent of the liability of the Department. The Department shall have no other obligation to the Recipient for termination. The Department may withhold from any amounts due the Recipient such sum as the Department determines to be necessary to protect the Department against potential loss or liability. The rights and remedies of the Department provided in this Agreement shall not be exclusive and are in addition to any other rights and remedies provided by law. After receipt of a notice of termination, and except as otherwise directed by the Department in writing, the Recipient shall: a. Stop work under the Agreement on the date, and to the extent specified, in the notice; b. Place no further orders or contracts for materials, services, supplies, equipment and/or facilities in relation to this Agreement except as may be necessary for completion of such portion of the work under the Agreement as is not terminated; C. Assign to the Department, in the manner, at the times, and to the extent directed by the Department, all of the rights, title, and interest of the RECIPIENT under the orders and contracts so terminated, in which case the Department has the right, at its discretion, to settle or pay any or all claims arising out of the termination of such orders and contracts; ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 7 of 11 City of Edmonds, E22-168 Revised Attachment C STATEMENT OF WORK Title Installation of All Hazards Alert Broadcast (AHAB) Warning Siren(s) within the City of Edmonds: The Recipient agrees to allow the installation of the All Hazards Alert Broadcast (AHAB) Warning Siren in the following locations within the City of Edmonds: AHAB Siren Name AHAB Siren Location (LAT/LONG) NA NA NA Point of Contact for Siren Location (Name, Phone Number, Email) The Department will provide all maintenance and parts to the controller box and satellite communications systems. The Department agrees to stock and maintain the standard repair components as suggested by the manufacturer to expedite repairs. All Hazards Alert Broadcast (AHAB) Warning Siren(s) requirements: Upon satisfactory installation, the siren will become the property of the Recipient. AC power hook-up will be provided by the Recipient to the siren but will not be hooked -up until the system has been installed on the pole. Continued monthly AC power usage charges will be required and provided through Recipient unless power is able to tie into existing electrical service. Battery replacement is the responsibility of the Recipient. Upon satisfactory installation, the Recipient will assume responsibility for: the physical security of the siren, for the coordination of the restoration of electrical power to the siren, for the routine testing of the siren via local radio network or internet, for the prompt reporting of any routine testing problems to the Department, and for access to the siren with a bucket truck and weed control within a 15-foot radius of the siren. If the siren will be installed in a locked area, the Recipient will provide 24-hour access and/or issue a key to the Washington Military Department Telecommunications Engineer to allow access to the area for times employees are unavailable to open the compound for needed work. The Department will send out a daily status report to Recipient, routinely test the siren with the satellite control system, automatically monitor alarms, silent test the siren, immediately report any intrusions to the Recipients Primary Law Enforcement agency, and troubleshoot and repair any major siren malfunctions as rapidly as possible (except for battery failures). The Department will schedule trained and certified siren technicians to troubleshoot and make repairs. The Recipient will be kept informed of all actions taken during repair. The Department agrees to maintain and fund the satellite access contracts with appropriate satellite providers. Upon notification by the Department, the Recipient has 48 hours to resolve any issue(s) with the batteries, AC power, physical security, and/or access to the Siren(s). Failure by the Recipient to fulfill this requirement will result in a management letter that may adversely impact future decision -making regarding the purchasing and installation of AHAB Siren(s) within the Recipient's jurisdiction. ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 9 of 11 City of Edmonds, E22-168 Revised Attachment D AHAB SITE SURVEY INFORMATION TEMPLATE Receiving Jurisdiction Responsibilities DETAILED INSTRUCTIONS: Choosing an Installation Location: 1. AC power is within an acceptable distance for installation. 2. Satellite transceiver antenna requires a clear view of sky to south-southeast (Approximately 198 degrees true and 30 degrees above horizon). 3. No overhead wires with a voltage rating of more than 14.41K volt AC or other obstructions within 20' of pole location. 4. No underground utilities within 5' of intended pole location. 5. Access for heavy equipment to install siren without blocking roads and no overhead obstructions. 6. Site must be in road right-of-way or municipal owned land. Other locations will require that the local jurisdiction negotiate and complete a legal easement agreement with the property owner. 7. All permitting necessary for installation must be obtained before the installation date. Documenting Installation Location: 1. Provide street number and name of nearest building. 2. Indicate siren location in relationship to that address. 3. Provide Latitude and Longitude readings. 4. Provide nearest cross streets both directions from install site. Distance from site to cross street is extremely helpful. Marking Installation Location (Installer responsibility after onsite survey is completed by Department Telecommunications Engineer): 1. Paint ground with White Paint 2. Drive a wood or metal stake into ground leaving — 2' exposed and marked with the words "SIREN". Requesting Underground Utility Check (Installer responsibility after onsite survey is completed): 1. Call the state-wide underground utility check number with the information collected above. 1- 800-424-5555 or www.callbeforeyoudiq org to schedule the underground utility check. 2. Mark all utilities within a 25' radius of the staked/marked location. 3. Pole will be installed 8-10' deep and ground wires extending out approximately 25' from the pole in one direction attached to 2 each, 10' ground rods. 4. Obtain a "ticket number" 5. Check the location after three (3) working days and see if any markings indicate utilities are under the intended install site. What happens next: 1. The Department will notify you the week before they are scheduled to install. Please realize that schedules often change due to weather and other unforeseen construction issues. We will do our best to keep you informed. 2. If required, the pole installer will update the underground utility check prior to pole installation using the ticket number. ALL HAZARDS ALERT BROADCAST (AHAB) SIREN Page 11 of 11 City of Edmonds, E22-168 Revised C zz- i�3 �1 �.�. N � I Qj �q i.:.� i'� �II l.� ,:i rr ... i• I�r� v'l R, t,� �,r�a� „i `•! >! �.�: ' o b -: 7 P l CONTACT INFORMATION Subrecipient Name (Agency, Local Government, or Organization): City of Edmonds WA Subrecipient Data Universal Numbering System (DUNS) / Unique Entity Identifier (UEI) Number: 040172827 Authorized Financial Representative (Name and Title): Charles T Wallace Address: 121 5th Ave. N Edmonds WA 98020 Email: Charles.wallace@edmondswa. ov Phone Number: (425) 218-6766 Directions: As required by 2 CFR Part 200 Subpart F, non-federal entities that expend $750,000 in federal awards in a fiscal year shall have a single or program -specific audit conducted for that year. If your entity is not subject to these requirements, you must complete Section A of this Form. If your entity is subject to these requirements, you must complete Section B of this form. All subrecipients must complete the Federal Funding Accountability and Transparency Act (FFATA) related questions in Section C of this Form. Failure to return this completed Form to contracts.office @mil.wa.gov may result in delay of grant agreement processing, withholding of federal awards or disallowance of costs, and suspension or termination of federal awards. SECTION A: Entities NOT subject to the audit requirements of 2 CFR Part 200 Subpart F [check oil that a I❑ We did not expend $750,000 or more of total federal awards during the preceding fiscal year. ❑ We are a for -profit organization. ❑ We are exempt for other reasons (describe): However, by signing below, I agree that we are still subject to the audit requirements, laws, and regulations governing the program(s) in which we participate; that we are required to maintain records of federal funding and to provide access to such records by federal and state agencies and their designees; and that WMD may request and be provided access to additional information and/or documentation to ensure proper stewardship of federal funds. SECTION 8: Entities that ARE subject to the audit requirements of 2 CFR Part 200 Subpart F (Complete the information below and check the appropriate box) ❑ We completed our last 2 CFR Part 200 Subpart F Audit on [enter date] for fiscal year [enter date]. There were no findings related to federal awards or internal controls. 0 We completed our last 2 CFR Part 200 Subpart F Audit on March 31, 2022 for fiscal year January 1, 2020 through December 31, 2020 and there were findings related to federal awards and/or internal controls. ❑ Our completed 2 CFR Part 200 Su art F Audit will be available on [enter date] for fiscal year [enter date]. Provide a complete copy of the audit report electronically to contracts.office@mil.wa.gov or provide the state audit number: Washington State Auditor's Office Report # 1030259 Updated 2/11/2020 Page 1 of 2 C2Z-/G�8 SECTION C. Federal Funding Accountability and Transparency Act (check the corresponding answers 1 In your preceding fiscal year, did your organization receive 80% or more of its gross revenues from federal funding? ❑ Yes ® No In your preceding fiscal year, did your organization receive $25,000,000 or more in federal funding? ❑ Yes ® No If you answered yes to the previous questions, WMD Contracts staff will request additional information to comply with FFATA reporting. I hereby certify that I am an individual authorized by the above identified entity (subrecipient) to complete this form. Further, I certify that the above information is true and correct, and all material findings contained in the audit report/statement have been disclosed. Additionally, I understand this form is to be submitted every fiscal year for which this entity is a subrecipient of federal award funds from the Department until the grant agreement is closed. J,, V4 Signature of Authorized Financial Representative: w po/ 202-3 Date: Click or tap to enter a date. Page 2 of 2 SIGNATURE AUTHORIZATION FORM WAJHINGTON STATE MILITARY DEPARTMENT* Camp Murray. Washin iton 98430-5122 Peas e d insuruc ions on reverse side before comp etkng this form. NAME OF ORGANIZATION DATE SUBMITTED City of Edmonds mi d0/2023 emi PROJECT :EJCRI TIO CONTWT�IU&ER QT �Iaza7`ds �I rt Bro do t (P�1AB) Sir n• • • • • E22-168 Revised 1 &&AUTHORIZING AUTHORITY SIGNATURE • PRINT OR TYPE NAMES •TITLE/TERM OF OFFICE • • ��� V\WWW 1 Charles Wallace Safe & Usast6v Coordinator 20 AUTHORIZED TO SIGN CONTRACTS/CONTRACT AMENDMENTS • • SIGNATURE PRINT OR TYPE NAME TITLE '� ` • • • Char>�s Wallatie ' � Sa ee & Disat r Coc�-d�ina o • • • I <e a son yor1 ' 3&&AUTHORIZED TO SIGN REQUESTS FOR REIMBURSEMEN SIGNATURE • PRINT OR TYPE NAME TITLE =C ar es a, ace - Safety &Disaster Coordinator \\NAC-1\V0L1\,HOME\KARENB\.... MMIGNAUTH Revised 3/03 40 INSTRUCTIONS FOR SIGNATURE AUTHORIZATION FORM This form identifies the persons who have the authority to sign contracts, amendments, and requests for reimbursement. It is required for the management of your contract with the Military Department (MD). Please complete all sections. One copy with original signatures is to be sent to MD with the signed contract, and the other should be kept with your copy of the contract. When a request for reimbursement is received, the signature is checked to verify that it matches the signature on file. The payment can be delayed if the request is presented without the proper signature. It is important that the signatures in MD's files are current. Changes in staffing or responsibilities will require a new signature authorization form. Authorizing Authority. Generally, the person(s) signing in this box heads the governing body of the organization, such as the board chair or mayor. In some cases, the chief executive officer may have been delegated this authority. 2. Authorized to Sign Contracts/Contract Amendments. The person(s) with this authority should sign in this space. Usually, it is the county commissioner, mayor, executive director, city clerk, etc. 3. Authorized to Sign Requests for Reimbursement. Often the executive director, city clerk, treasurer, or administrative assistant have this authority. It is advisable to have more than one person authorized to sign reimbursement requests. This will help prevent delays in processing a request if one person is temporarily unavailable. If you have any questions regarding this form or to request new forms, please call your MD Program Manager. Washington Military Department Contract Number: ` - ' &3 Debarment, Suspension, Ineligibility or Voluntary Exclusion Certification Form NAME Doing business as (DBA) City of Edmonds ADDRESS Applicable Procurement WA Uniform Business Federal Employer Tax 121 5th Ave. N., Edmonds, WA 98020 or Solicitation #, if any: Identifier (UBI) Identification #: 312-000-093 91-6001244 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 st to is in this certification, such prospective participant shall attach an explanation to this form. r 1 f Bidder or Contractor Signature: LDate: 01/10/2023 Print Name and Title: Charles Wallace, Safety & Disaster Coordinator Washington Military Department Contract Number: E22-168 FEDERAL DEBARMENT, SUSPENSION INELIGIBILITY and VOLUNTARY EXCLUSION (FREQUENTLY ASKED QUESTIONS) What is "Debarment Suspension, Ineli-gibility, and Voluntary Exclusion"? These terms refer to the status of a person or company that cannot contract with or receive grants from a federal agency. In order to be debarred, suspended, ineligible, or voluntarily excluded, you must have: had a contract or grant with a federal agency, and gone through some process where the federal agency notified or attempted to notify you that you could not contract with the federal agency. • Generally, this process occurs where you, the contractor, are not qualified or are not adequately performing under a contract, or have violated a regulation or law pertaining to the contract. Why am I required to sign this certification? You are requesting a contract or grant with the Washington Military Department. Federal law (Executive Order 12549) requires Washington Military Department ensure that persons or companies that contract with Washington Military Department are not prohibited from having federal contracts. What is Executive Order 12549? Executive Order 12549 refers to Federal Executive Order Number 12549. The executive order was signed by the President and directed federal agencies to ensure that federal agencies, and any state or other agency receiving federal funds were not contracting or awarding grants to persons, organizations, or companies who have been excluded from participating in federal contracts or grants. Federal agencies have codified this requirement in their individual agency Code of Federal Regulations (CFRs). What is the purpose of this certification? The purpose of the certification is for you to tell Washington Military Department in writing that you have not been prohibited by federal agencies from entering into a federal contract. What does the word "Proposal" mean when referred to in this certification? Proposal means a solicited or unsolicited bid, application, request, invitation to consider or similar communication from you to Washington Military Department. What or who is a "lower tier participant"? Lower tier participants means a person or organization that submits a proposal, enters into contracts with, or receives a grant from Washington Military Department, OR any subcontractor of a contract with Washington Military Department. If you hire subcontractors, you should require them to sign a certification and keep it with your subcontract. What is a covered transaction when referred to in this certification? Covered Transaction means a contract, oral or written agreement, grant, or any other arrangement where you contract with or receive money from Washington Military Department. Covered Transaction does not include mandatory entitlements and individual benefits. Sample Debarment, Suspension, Ineligibility, Voluntary Exclusion Contract Provision Debarment Certification. The Contractor certifies that the Contractor is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participating in this Contract by any Federal department or agency. If requested by Washington Military Department, the Contractor shall complete a Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion form. Any such form completed by the Contractor for this Contract shall be incorporated into this Contract by reference.