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23 <br />DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />DIVISION OF PUBLIC HEALTH <br />FEDERAL CERTIFICATIONS <br />The undersigned states that: <br />1. He or she is the duly authorized representative of the Contractor named below; <br />2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, as set out herein: <br />a. The Certification Regarding Nondiscrimination; <br />b. The Certification Regarding Drug -Free Workplace Requirements; <br />c_ The Certification Regarding Environmental Tobacco Smoke; <br />d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered <br />Transactions; and <br />e. The Certification Regarding Lobbying; <br />3. He or she has completed the Certification Regarding Drug -Free Workplace Requirements by providing the addresses at which the <br />contract work will be performed; <br />4. [Check the applicable statement] <br />❑ He or she has completed the attached Disclosure Of Lobbying Activities because the Contractor has made, or has an <br />agreement to make, a payment to a lobbying entity for.influencing or attempting to influence an officer or employee of an <br />agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection <br />with a covered Federal action; <br />a <br />❑ He or she has not completed the attached Disclosure Of Lobbying Activities because the Contractor has not made, and <br />has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or <br />employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of <br />Congress in connection with a covered Federal action.' <br />5. . The Contractor shall require its subcontractors, if any, to make the same certifications. and disclosure. <br />Signature <br />Contracting Agency's Legal Name <br />Title <br />Date <br />IThis Certification dust Be Signed By The Same Individual Who Signed the Contract.) <br />1. Certification Regarding Nondiscrimination <br />The Contractor certifies that it will comply with all federal statutes relating to nondiscrimination. These include but are not limited <br />to: (a) 'Title VI of the Civil Rights .let of 1964 (P.L. 88 -352) which_ prohibits discrimination on the basis of race. color or national <br />origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. $ §1681 -1683, and 3685- 1686), which prohibits <br />discrimination on the basis of sex; (e) Section 504 of the Rehabilitation .Act of 1973. as amended (39 U.S.C. k794). which prohibits <br />discrimination on the basis of handicaps: (d) the age Discrimination Act of 19?5. as amended (43 U.S.C. ;,611)1- 6107), which <br />prohibits discrimination on the basis of age: (c) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 -355), as amended, relating <br />to nondiscrimination on the basis of drug abuse; (t) the Comprehensive alcohol abuse and Alcoholism Prevention, Treatment and <br />Rehabilitation act of 19770 (P.L. 91 -616). as amended. relating to nondiscrimination on the basis of alcohol abuse or alcoholism; fgl <br />Federal Certifications 06/24/09 Page 1. of 4 <br />