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Applicants should refer to the regulations cited below to determine the
certification to which they are required to attest. Applicants should
also review the instructions for certification included in the
regulations before completing this form. Signature on this form
provides for compliance with certification requirements under 44 CFR
Part 18, "New Restrictions on Lobbying; and 44 CFR Part 17,
"Government-wide Debarment and Suspension (Non-procurement) and
Government-wide Requirements for Drug-Free Workplace (Grants)." The
certifications shall be treated as a material representation of fact
upon which reliance will be placed when the Department of Homeland
Security (DHS) determines to award the covered transaction, grant, or
cooperative agreement. |
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1. LOBBYING
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A. As required by the section 1352, Title 31 of the US Code, and
implemented at 44 CFR Part 18 for persons (entering) into a grant or cooperative
agreement over $100,000, as defined at 44CFR Part 18, the applicant
certifies that:
(a) No Federal appropriated funds have been paid or will be paid
by or on behalf of the undersigned to any person for influencing
or attempting to influence an officer or employee of any agency,
a Member of Congress, an officer or employee of congress, or an
employee of a Member of Congress in connection with the making
of any Federal grant, the entering into of any cooperative agreement
and extension, continuation, renewal amendment or modification
of any Federal grant or cooperative agreement.
(b) If any other funds than Federal appropriated funds have been
paid or will be paid to any person for influencing or attempting
to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of congress, or an employee of
a Member of Congress in connection with this Federal grant or
cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure of Lobbying Activities",
in accordance with its instructions.
(c) The undersigned shall require that the language of this certification
be included in the award documents for all the sub awards at all
tiers (including sub grants, contracts under grants and cooperative
agreements and sub contract(s)) and that all sub recipients shall
certify and disclose accordingly.
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2. Debarment, Suspension and Other Responsibility
Matters (Direct Recipient)
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A. As required by Executive Order 12549, Debarment and Suspension,
and implemented at 44CFR Part 67, for prospective participants in
primary covered transactions, as defined at 44 CFR Part 17, Section
17.510-A, the applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits
by a State or Federal court, or voluntarily excluded from covered
transactions by any Federal department or agency.
(b) Have not within a three-year period preceding this application
been convicted of or had a civilian judgment rendered against
them for commission of fraud or a criminal offense in connection
with obtaining, attempting to obtain or perform a public (Federal,
State, or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission
of embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property.
(c) Are not presently indicted for or otherwise criminally or
civilly charged by a government entity (Federal, State, or local)
with commission of any of the offenses enumerated in paragraph
(1)(b) of this certification: and
(d) Have not within a three-year period preceding this application
had one or more public transactions (Federal, State, or local)
terminated for cause or default; and
B. Where the applicant is unable to certify to any of the statements
in this certification, he or she shall attach an explanation to
this application.
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3. Drug-Free Workplace (Grantees other than individuals)
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As required by the Drug-Free Workplace Act of 1988, and implemented
at 44CFR Part 17, Subpart F, for grantees, as defined at 44 CFR
part 17, Sections 17.615 and 17.620:
(A) The applicant certifies that it will continue to provide
a drug-free workplace by:
(a) Publishing a statement notifying employees that the unlawful
manufacture, distribution, dispensing, possession, or use of
a controlled substance is prohibited in the grantee's workplace
and specifying the actions that will be taken against employees
for violation of such prohibition;
(b) Establishing an on-going
drug free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantees policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation and employee
assistance programs; and
(4) The penalties that may be imposed upon employees for drug
abuse violations occurring in the workplace;
(c) Making it a requirement that each employee to be engaged in
the performance of the grant to be given a copy of the statement
required by paragraph (a);
(d) Notifying the employee in the statement required by paragraph
(a) that, as a condition of employment under the grant, the employee
will:
(1) Abide by the terms of the statement and
(2) Notify the employee in writing of his or her conviction
for a violation of a criminal drug statute occurring in the
workplace no later than five calendar days after such conviction.
(e) Notifying the agency, in writing within 10 calendar days after
receiving notice under subparagraph (d)(2) from an employee or
otherwise receiving actual notice of such conviction. Employers
of convicted employees must provide notice, including position
title, to the applicable DHS awarding office, i.e. regional office
or DHS office.
(f) Taking one of the following actions, against such an employee,
within 30 calendar days of receiving notice under subparagraph
(d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an
employee, up to and including termination, consistent with
the requirements of the Rehabilitation Act of 1973, as amended;
or
(2) Requiring such employee to participate satisfactorily
in a drug abuse assistance or rehabilitation program approved
for such purposes by a Federal, State, or local health, law
enforcement or other appropriate agency.
(g) Making a good faith effort to continue to maintain a drug
free workplace through implementation of paragraphs (a), (b),
(c), (d), (e), and (f).
(B) The grantee may insert in the space provided below the site(s)
for the performance of work done in connection with the specific
grant:
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Place of Performance
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City |
State |
Zip |
Action |
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