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<br /> a
<br /> CERTIFICATIONS REGARDING(A) DEBARNiE.NT,SUSI'ENSiON AND OTIIER RESi'ONSIBILiTY MATTERS;
<br /> (B)DRUG-FREE WORKPLACE,RF,t2UIREMENTS;AND(C) LOBBYING
<br /> Applicants should refer to the regulations cited below to determine which ccitifica!ion(s) apply to their grant,and review the instnnetions included in the
<br /> regulations. Signing this form complies with certification requirements under "Government-wide Debarment and Suspension (Nonprocurement)" and
<br /> "Government-wide Requirements forDrug-Free Workplace(Grants)"(under-15 CFK Part 1229),and"New Restrictions on Lobbying"(under 45 CFR Part 1230).
<br /> The certification(s)shall be treated as material representation of fact upon which reliance will be placed when the Corporation determines to award the covered
<br /> transaction,grant,or cooperative agreement.
<br /> A. DEBARMENT,SUSPENSION,AND OTHER RESPONSIBiL- criminal drug statute which occurred in(he workplace,no later than
<br /> ITY MATTERS five calendar days after such conviction;
<br /> As required by Executive Order 12549, Debarment and Suspension, and (c)Notify the cognizant Corporation Grants Officer within ten calendar
<br /> implemented at 45 CFR Part 1229, for prospective participants in primacy daysaRer receiving notice of such conviction under subparagraph(d)(2)
<br /> covered transactions,as defined at 45 Ci-R Part 1229,Sections 1229.105 and front the employee,or otherwise receiving actual notice. The notice
<br /> 1229.110— shall include the title of the employee's position and the identification
<br /> 1. The applicant certifies that it and its principals: awnber(s)or each affected gran(;
<br /> (a) Are not presently debarred, suspended, proposed for debarment, (f)'hake one of the following actions,within 30 calendar days of receiving
<br /> declared ineligible,or voluntarily excluded from covered Uano-ac- notice under subpk-uagraph 46,with respect to any employee who is so
<br /> lions by any Federal department or agency; convicted—
<br /> (b) Have no(, witldn a three-year period preceding this application, (I)Take appropriate personnel action against such an employee up to
<br /> been convicted of or had acivil judgment rendered against them for and including termination consistent with the requirements of the
<br /> commission of fraud or a criminal offense in connection with RchaHlitation Act of 1973,as amended;or
<br /> obtaining,attempting to obtain,or performing a public (Fede:al, (2)Require such employee to participate satisfactorily in a drug abuse
<br /> State or local)transaction or contract under a public transaction; assistance or rehabilitation program approved for such purposes by
<br /> violation of Federal or State antitrust statutes or commission of a Fcdcral,Slate or local licalth,law enforcement,or other appropri-
<br /> embezzlement,theil,forgery,bribery,falsi ficatibn or destruction of ate agency;
<br /> records,making false statements,or receiving stolen propery-, (g)Make a good faith effort to continue to maintain a drug-free workplace
<br /> (c) Are not presently indicted for or otherwise criminally or civilly through implementation of paragraphs I(a)through 1(p.
<br /> charged by a Federal,State or local governnnententity wit heomrmis_ 2• 'Ilse grantee shall insert in the space provided below the site(s) for the
<br /> sion of any of the offenses enumerated in paragraph I(b)of this performance of work done in connection with the specific grant:
<br /> certification; Place of Performance(Street address,city,county,state,zip code):
<br /> (d) Have not,within a three-year period preceding this application,had
<br /> one or more public transactions(Federal.State or local)terminated
<br /> for cause or default;and _-
<br /> 2. Where the applicant is unable to certify to any of the statements in this U. Check here if there arc grantee workplaces that are not identified above.
<br /> certification,he or she shall attach an explanation to this application. C. LOBBYING
<br /> B.DRUG-FREEWORKPLACE(GRANTEES 01'1lER TIIAN As required by Section 1352,Title 31 of the U.S.'Code,and implemented
<br /> INDIVIDUALS) at 45 CPR['art 1230,for organizations entering into a grant or cooperative
<br /> As required by the Drug-Free Workplace Act of 1988,and implemented at 45 ng-cement over 31(0,000,as dcfrned at 45 C17R Part 1230,Sections
<br /> CM Part 1229, Subpart F, for grantees, as defmcd at 45 CFR Part 1229, 1230.1105 and 1230.1 10,ifie applicant certifies that:
<br /> Sections 1229.605 and 1229.610— L No Federal appropriated funds have been paid or will be paid,by or on
<br /> 1.The applicant certifies that it will or will continue to provide a drug-free behalf of the undersigned,to any person for influencing or attempting to
<br /> workplace,and will: inllucnce an officer or employee of any agency,a Member of Congress,
<br /> (a)Publish astatement notifying employees that the unlawful manufacture, an officer or employee of Congress,or an employee of a Member of
<br /> distribution,dispensing,possession or use of a controlled substance is Congress in connection with the awarding of any Federal contract,the
<br /> prohibited in the grantee's workplace and specifying the actions that will making of any Federal grant,the making of any Federal loan,the
<br /> be taken against employees for violation of such prohibition; criering into of any cooperative agreement,or the extension,continua-
<br /> (b)Establish an on-going drug-free awareness program to inform employ- lion,renewal,amendment,or modification of any Federal contract,
<br /> ecs about— grant,loan,or cooperative agreement.
<br /> (1)The dangers of drug abuse in the workplace; 2. if any funds other than Federal appropriated funds have been paid or
<br /> (2)The grantee's policy of maintaining a drug-free workplace; will be paid to airy person for influencing or attempting to influence an
<br /> (3)Any available drug counseling,rehabilitation,and employee as-as- of ricer or employee of any agency,a Member of Congress,an officer or
<br /> Lance programs;and employee of Congress,or art employee of a Member of Congress in
<br /> (4)The penalties that may be imposed upon employees for drug abuse connection with this Federal contract,grant,loan,or cooperative
<br /> violations occurring in the workplace. agreement,the undersigned shall complete and submit Standard Form-
<br /> (c)Make it a requirement that each employee to be engaged in the perfor- LLL,"Disclosure Fonn to Rcport Lobbying,"in accordance with its
<br /> mance of the grant be given a copy of the statement required by instnrc(ions.
<br /> paragraph I(n); 3. The undersigned shall require(hat the language of this certification be
<br /> (d)Notify the employee inthestalementrequircdbysubparagraph 1(a)thdt, included in the award documents for all subcontracts at all tiers
<br /> as a condition of employment under the grant,the employee will— (including subcontracts,subgrants,and contracts under grants,loans,
<br /> (1)Abide by the temis of the statement;and at,,:cooperative agreements)and that all subrecipients shall certify and
<br /> (2)Notify the employer in writing of any conviction for a violation of a Jisclose accordingly.
<br /> As the duly a,ahorized representative of the applicant,I hereby certify that rite app scant will comply with the above certilication(s). A copy o the governing
<br /> body's authorization for me to sign this certification as official representative is oil file in(he applicant's office.)
<br /> Applicant Organization Printed Nante and'hitle of Authorized Representative
<br /> Signature of Authorized Certifying Official Date
<br /> Corporation ronli 4240-C (4/94)
<br /> Page 11.0 PAGE 15
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