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DEPARTMENT OF HOMELAND SECURITY
<br /> FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B.No. 1660-0025
<br /> CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER Expires November 30,2013
<br /> RESPONSIBILITY MATTERS;AND DRUG-FREE WORKPLACE REQUIREMENTS
<br /> PAPERWORK BURDEN DISCLOSURE NOTICE
<br /> Public reporting burden for this data collection is estimated to average 1.7 hours per response.The burden estimate includes the time for reviewing instructions,
<br /> searching existing data sources,gathering and maintaining the data needed,and completing and submitting this form.This collection of information is required
<br /> to obtain or retain benefits.You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form.Send
<br /> comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:Information Collections Management,Department of
<br /> Homeland Security Federal Emergency Management Agency, 1800 South Bell Street,Arlington,VA 20598-3005 Paperwork Reduction Project(1660-0025).
<br /> NOTE:Do not send your completed form to this address.
<br /> Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the
<br /> instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification
<br /> requirements under 44 CFR Part 18,"New Restrictions on Lobbying"and 28 CFR Part 17, "Government-wide Debarment and Suspension (Nonprocurement)
<br /> and Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material representation of fact upon which
<br /> reliance will be placed when the Federal Emergency Management Agency(FEMA)determines to award the transaction,grant,or cooperative agreement.
<br /> 1. LOBBYING (c)Are not presently indicted for otherwise criminally or civilly charged by a
<br /> governmental entity(Federal,State,or local)with commission of any of the
<br /> As required by section 1352,Title 31 of the U.S.Code,and implemented offenses enumerated in paragraph(1)(b)of this certification;and
<br /> at 44 CFR Part 18,for persons entering into a grant or cooperating
<br /> agreement over$100,000,as defined at 44 CFR Part 18,the applicant (d)Have not within a three-year period preceding this application had one or
<br /> certifies that: more public transactions(Federal,State,or local)terminated for cause of
<br /> (a)No Federal appropriated funds have been paid or will be paid,by or on default;and
<br /> behalf of the undersigned,to any person for influencing or attempting to B. Where the applicant is unable to certify to any of the statements in this
<br /> influence an officer or employee of any agency,a Member of Congress, an certification,he or she shall attach an explanation to this application.
<br /> officer or employee of Congress,or an employee of a Member of Congress
<br /> in connection with the making of any Federal grant,the entering into of any
<br /> cooperative agreement,and the extension,continuation,renewal, 3. DRUG-FREE WORKPLACE
<br /> amendment,or modifib�tion of any Federal grant or cooperative (GRANTEE OTHER THAN INDIVIDUALS)
<br /> agreement.
<br /> (b)If any other funds than Federal appropriated funds have been paid or will be As required by the Drug-Free Workplace Act of 1988,and implemented at
<br /> paid to any other person for influencing or attempting to influence an officer 44 CFR Part 17,Subpart F,for grantees,as defined at 44 CFR Part 17.615
<br /> or employee of any agency,a member of Congress,an officer or an and 17.620-
<br /> employee of Congress,or employee of a member of Congress in A. The applicant certifies that it will continue to provide a drug-free
<br /> connection with this Federal Grant or cooperative agreement,the workplace by; :
<br /> undersigned shall complete and submit Stand Form-LLL,"Disclosure of
<br /> Lobbying Activities,",in accordance with its instructions. (a)Publishing a,statement notifying employees that the unlawful
<br /> manufacture,clfistrlbution,dispensing,possession,or use of a controlled
<br /> c)The undersigned;shall require that the language of this certification be
<br /> included in ftiPaward documents for all subawards at all tiers(including substance is prohibited in the grantee's workplace and specifying the
<br /> subgrants,contracts under grants and cooperative agreements,and actions that will be taken against employees for violation of such
<br /> subcontracts)and that all subrecipients shall certify and disclose prohibition;
<br /> accordingly. (b) Establishing an on-going drug free awareness program to inform
<br /> r' Staddard Form-LLL"Disclosure of Lobbying Activities"attached employees about-
<br /> (This form must be attached to certification if nonappropriated funds are to (1)The dangers of drug abuse in the workplace;
<br /> be used to influence activities.)
<br /> 2. DEBARMENT,SUSPENSION, AND OTHER RESPONSIBILITY (2)The grantee's policy of maintaining a drug-free workplace;
<br /> MATTERS(DIRECT RECIPIENT) (3)Any available drug counseling, rehabilitation, and
<br /> As required by Executive Order 12549,Debarment and Suspension,and employee assistance programs;and
<br /> implemented at 44 CFR Part 67,for prospective participants in primary (4)The penalties that may be imposed upon employees
<br /> covered transactions,as defined at 44 CFR Part 17,Section 17.510-A. for drug abuse violations occurring in the workplace;
<br /> A. The applicant certifies that it and its principals: (c) Making it a requirement that each employee to be engaged in the
<br /> (a)Are not presently debarred,suspended,proposed for debarment, performance of the grant to be given a copy of the statement required by
<br /> declared ineligible,sentenced to a denial of Federal benefits by a State or paragraph(a);
<br /> Federal court,or voluntarily excluded from covered transactions by any
<br /> Federal department or agency; (d) Notifying the employee in the statement required by paragraph(a)that,
<br /> (b)Have not within athree-year period preceding this application been as a condition of employment under the grant,the employee will-
<br /> convicted of a or had a civilian judgment rendered against them for (1)Abide by the term of the statement;and
<br /> commission of fraud or a criminal offense in connection with obtaining,
<br /> attempting to obtain,or perform a public a public(Federal,State,or local) (2) Notify the employee in writing of his or her conviction for a
<br /> transaction or contract under a public transaction;violation of Federal or violation of a criminal drug statute occurring ion the workplace no
<br /> State antitrust statutes or commission of embezzlement,theft,forgery, later than five calendar days after such convictions;
<br /> bribery,falsification or destruction of records,making false statements,or
<br /> receiving stolen property;
<br /> FEMA Form 112-0-3C(11/2010) PREVIOUS EDITION OBSOLETE
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