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______________________________________________________________________________________________ <br />City, State, Zip Code <br />_______________________________________________________________________________________________ <br />Street <br />_______________________________________________________________________________________________ <br />City, State, Zip Code <br />_______________________________________________________________________________________________ <br /> <br />3. Contractor will inform the Department of any additional sites for performance of work under this agreement. <br /> <br />4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination <br />of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510. <br /> <br /> <br />III. Certification Regarding Environmental Tobacco Smoke <br /> <br />Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires <br />that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used <br />routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if <br />the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, <br />loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely <br />by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply <br />with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the <br />imposition of an administrative compliance order on the responsible entity. <br /> <br />The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will <br />require the language of this certification be included in any subawards that contain provisions for children's services and <br />that all subgrantees shall certify accordingly. <br /> <br />IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier <br />Covered Transactions <br /> <br />Instructions <br /> <br />[The phrase "prospective lower tier participant" means the Contractor.] <br /> <br />1. By signing and submitting this document, the prospective lower tier participant is providing the certification set out <br />below. <br /> <br />2. The certification in this clause is a material representation of the fact upon which reliance was placed when this <br />transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an <br />erroneous certification, in addition to other remedies available to the Federal Government, the department or agency <br />with which this transaction originate may pursue available remedies, including suspension and/or debarment. <br /> <br />3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is <br />submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted <br />or has become erroneous by reason of changed circumstances. <br /> <br />4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," <br />"person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have <br />the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR <br />Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those <br />regulations. <br /> <br />5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction <br />be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended, <br />DocuSign Envelope ID: 4D4C41ED-9F19-4257-801C-59178B514BD4