2014-206 Health - NC Dept. of Health and Human Services Division of Public Health - FY 2015 Consolidated Agreement

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Consolidated Agreement FY 15 Page 22 of 28 FEDERAL CERTIFICATIONS The undersigned states that: 1. He or she is the duly authorized representative of the Contractor named below; 2. He or she is authorized to make,and does hereby make,the following certifications on behalf of the Contractor,as set out herein: a. The Certification Regarding Nondiscrimination; b. The Certification Regarding Drug-Free Workplace Requirements; c. The Certification Regarding Environmental Tobacco Smoke; d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; and e. The Certification Regarding Lobbying; 3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses at which the contract work will be performed; 4. [Check the applicable statement] ❑ He or she has completed the attached Disclosure of Lobbying Activities because the Contractor has made,or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action; OR He or she has not completed the attached Disclosure of Lobbying Activities because the Contractor has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or employee of any agency,any Member of Congress,any officer or employee of Congress, or any employee of a Member of Congress in connection with a covered Federal action. 5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure. _/)I)fCt Signature Title Orange County Health Department l Contractor[Organization's] Legal Name Date [This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.] I. Certification Regarding Nondiscrimination The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination.These include but are not limited to:(a)Title VI of the Civil Rights Act of 1964(P.L.88-352)which prohibits discrimination on the basis of race,color or national origin; (b)Title IX of the Education Amendments of 1972, as amended(20 U.S.C. §§1681-1683,and 1685-1686), which prohibits discrimination on the basis of sex;(c)Section 504 of the Rehabilitation Act of 1973,as amended(29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107),which prohibits discrimination on the basis of age;(e)the Drug Abuse Office and Treatment Act of 1972 (P.L.92-255),as amended,relating to nondiscrimination on the basis of drug abuse;(f)the Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation Act of 1970(P.L.91-616),as amended,relating to nondiscrimination on the basis of alcohol abuse or alcoholism;(g)Title VIII of the Civil Rights Act of 1968(42 U.S.C. §§3601 et seq.),as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and(i)the requirements of any other nondiscrimination statutes which may apply to this Agreement.