Certifications and Assurance by jolinmilioncherie


									                                   ATTACHMENT 5
                           CERTIFICATIONS AND ASSURANCES


          Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) 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 an agency, a Member of Congress, an officer or employee of Congress, or an employee of
    a Member of Congress in connection with the awarding of any Federal contract, the making
    of any Federal grant, the making of any Federal loan, the entering into of any cooperative
    agreement, and the extension, continuation, renewal, amendment, or modification of any
    Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other 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 contract, grant, loan, or cooperative agreement, the
    undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report
    Lobbying,” in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award
    documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
    under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and
    disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure.



______ I am unable to certify to the above statements. My explanation is:
                                                           ATTACHMENT 5
                                 DISCLOSURE OF LOBBYING ACTIVITIES
                         Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

1. Type of Federal Action:                        2. Status of Federal Action:                         3. Report Type:
      a. contract                                             a.    bid/offer/application                     a. initial filing
      b. grant                                                b.    initial award                             b. material change
      c. cooperative agreement                                c.    post-award                                For Material Change Only:
      d. loan                                                                                                 year_______quarter______
      e. loan guarantee                                                                                       date of last report_________
      f. loan insurance
4. Name and Address of Reporting Entity:                      5. If Reporting Entity in No. 4 is Subawardee, Enter Name
        Prime                 Subawardee                      and Address of Prime:
                             Tier_______, if known:

Congressional District, if known:                             Congressional District, if known:
6. Federal Department/Agency:                                 7. Federal Program Name/Description

                                                              CFDA Number, if applicable: ________________________

8. Federal Action Number, if known:                           9. Award Amount, if known: $ ________________________

10.a. Name and Address of Lobbying Entity                     b. Individuals Performing Service (including address if different from 10a)
       (if individual, last name, first name, MI):            - (last name, first name, MI):

                                                    (attach Continuation Sheet(s) if necessary)

11. Amount of Payment (check all that apply):                               13. Type of Payment (check all that apply):
 $ ______________            actual         planned                                      a. retainer
12. Form of Payment (check all that apply):                                              b. one-time fee
                                                                                         c. commission
      a. cash                                                                            d. contingent fee
      b. in kind; specify: nature _________________                                      e. deferred
                            value _________________                                      f. other, specify:

14. Brief Description of Services Performed or to be Performed and Date (s) of Services, including officer (s), employee(s), or
Member(s) contacted, for Payment Indicated in Item 11:

                                                  (attach Continuation Sheet(s) if necessary)

15. Continuation Sheet(s) attached:             Yes            No

16. Information required through this form is authorized by title 31        Signature:
U.S.C. section 1352. This disclosure of lobbying activities is a material
representation of fact upon which reliance was placed by the tier above     Print Name:
when this transaction was made or entered into. This disclosure is
required pursuant to 31 U.S.C. section 1352. This information will be       Title:
reported to the Congress semiannually and will be available for public      Telephone No.:                          Date:
inspection. Any person who fails to file the required disclosure shall be
subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.

Federal Use Only:                                                                                      Authorized for Local Reproduction
                                                                                                       Standard Form - LLL
                                        ATTACHMENT 5


This disclosure form shall be completed by the reporting entity, whether subawardee or
prime Federal recipient, at the initiation or receipt of a covered Federal action, or a
material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of
a form is required for each payment or agreement to make payment to any lobbying entity
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 a covered Federal action. Use the SF-LLL-A Continuation Sheet for
additional information if the space on the form is inadequate. Complete all items that apply
for both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been
secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a
material change to the information previously reported, enter the year and quarter in which the
change occurred. Enter the date of the last previously submitted report by this reporting entity for
this covered Federal action.

4. Enter the full name, address, city, state and zip code of the reporting entity. Include
Congressional District, if known. Check the appropriate classification of the reporting entity that
designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the
subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not
limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks “Subawardee”, then enter the full name,
address, city, state and zip code of the prime Federal recipient. Include Congressional District, if

6. Enter the name of the Federal agency making the award or loan commitment. Include at least
one organizational level below agency name, if known. For example, Department of
Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If
known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants,
cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action
identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number;
grant announcement number; the contract, grant, or loan award number; the application/proposal
control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001".

9. For a covered Federal action where there has been an award or loan commitment by the
Federal agency, enter the Federal amount of the award/loan commitment for the prime entity
identified in item 4 or 5.

10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by
the reporting entity identified in item 4 to influence the covered Federal action.

     (b) Enter the full names of the individual(s) performing services, and include full address if
different from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).

11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting
entity (item 4) to the lobbying entity (item 10). Indicate whether the payment has been made
(actual) or will be made (planned). Check all boxes that apply. If this is a material change report,
enter the cumulative amount of payment made or planned to be made.

12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-
kind contribution, specify the nature and value of the in-kind payment.

13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.

14. Provide a specific and detailed description of the services that the lobbyist has performed, or
will be expected to perform, and the date(s) of any services rendered. Include all preparatory and
related activity, not just time spent in actual contact with Federal officials. Identify the Federal
official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress
that were contacted.

15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.

16. The certifying official shall sign and date the form, print his/her name, title, and telephone

Public reporting burden for this collection of information is estimated to average 30 minutes per
response, including time for reviewing instruction, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0046), Washington, D.C. 20503.
                                                        ATTACHMENT 5
                                           ASSURANCES AND CERTIFICATIONS
                                            NON-CONSTRUCTION PROGRAMS
            NOTE: Certain of these assurances may not be applicable to your project or program. If you have questions, please
            contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to additional
            assurances. If such is the case, you will be notified.
     As the duly authorized representative of the applicant, I certify that the applicant:

1.    Has the legal authority to apply for Federal assistance                   Public Health Service Act of 1912 (42 U.S.C. §§290
      and the institutional, managerial and financial                           dd-3 and 290 ee-3), as amended, relating to
      capability (including funds sufficient to pay the non-                    confidentiality of alcohol and drug abuse patient
      Federal share of project cost) to ensure proper                           records; (h) Title VIII of the Civil Rights Act of 1968
      planning, management and completion of the project                        (42 U.S.C. §§3601 et seq.), as amended, relating to
      described in this application.                                            nondiscrimination in the sale, rental or financing of
                                                                                housing; (i) any other nondiscrimination provisions in
2.    Will give the Foundation, the awarding agency, the                        the specific statute(s) under which application for
      Comptroller General of the United States and, if                          Federal assistance is being made; and (j) the
      appropriate, the State, through any authorized                            requirements of any other nondiscrimination statute(s)
      representative, access to and the right to examine all                    which may apply to the application
      records, books, papers, or documents related to the
      award; and will establish a proper accounting system                7.    Will comply, or has already complied, with the
      in accordance with generally accepted accounting                          requirements of Titles II and III of the Uniform
      standards or agency directives.                                           Relocation Assistance and Real Property Acquisition
                                                                                Policies Act of 1970 (P.L. 91-646) which provide for
3.    Will establish safeguards to prohibit employees from                      fair and equitable treatment of persons displaced or
      using their positions for a purpose that constitutes or                   whose property is acquired as a result of Federal or
      presents the appearance of personal or organizational                     federally-assisted programs. These requirements
      conflict of interest, or personal gain.                                   apply to all interests in real property acquired for
                                                                                project purposes regardless of Federal participation in
4.    Will initiate and complete the work within the                            purchases
      applicable time frame after receipt of approval of The
      Foundation.                                                         8.    Will comply, as applicable, with provisions of the
                                                                                Hatch Act (5 U.S.C. §§1501-1508 and 7324-
5.    Will comply with the Intergovernmental Personnel                          7328)which limit the political activities of employees
      Act of 1970 (42 U.S.C. §§4728-4763) relating to                           whose principal employment activities are funded in
      prescribed standards for merit systems for programs                       whole or in part with Federal funds.
      funded under one of the 19 statutes or regulations
      specified in Appendix A of OPM’s Standards for a                    9.    Will comply, as applicable, with the provisions of the
      Merit System of Personnel Administration (5 C.F.R.                        Davis-Bacon Act (40 U.S.C. §§276a to 276a-7), the
      900, Subpart F).                                                          Copeland Act (40 U.S.C. §276c and 18 U.S.C. §874),
                                                                                and the Contract Work Hours and Safety Standards
6.    Will comply with all Federal statutes relating to                         Act(40 U.S.C. §§327-333), regarding labor standards
      nondiscrimination. These include but are not limited                      for federally-assisted construction sub-agreements.
      to: (a) Title VI of the Civil Rights Act of 1964 (P.L.
      88-352) which prohibits discrimination on the basis of              10. Will comply, if applicable, with flood insurance
      race, color or national origin:; (b) Title IX of the                    purchase requirements of Section 102(a) of the Flood
      Education Amendments of 1972, as amended (20                            Disaster Protection Act of 1973 (P.L. 93-234) which
      U.S.C. §§1681-1683, and 1685-1686), which prohibits                     requires recipients in a special flood hazard area to
      discrimination on the basis of sex; c) Section 504 of                   participate in the program and to purchase flood
      the Rehabilitation Act of 1973, as amended (29                          insurance if the total cost of insurable construction and
      U.S.C. §§794), which prohibits discrimination on the                    acquisition is$10,000 or more.
      basis of handicaps; (d) the Age Discrimination Act of
      1975, as amended (42 U.S.C. §6101-6107), which                      11. Will comply with environmental standards which may
      prohibits discrimination on the basis of age; (e) the                   be prescribed pursuant to the following: (a) institution
      Drug Abuse Office and Treatment Act of 1972 (P.L.                       of environmental quality control measures under the
      92-255), as amended, relating to nondiscrimination on                   National Environmental Policy Act of 1969 (P.L. 91-
      the basis of drug abuse; (f) the Comprehensive                          190) and Executive Order (EO) 11514; (b) notification
      Alcohol Abuse and Alcoholism Prevention, Treatment                      of violating facilities pursuant to EO 11738; c)
      and Rehabilitation Act of 1970 (P.L. 91-616), as                        protection of wetlands pursuant to EO 11990; (d)
      amended, relating to nondiscrimination on the basis of                  evaluation of flood hazards in floodplains in
      alcohol abuse or alcoholism; (g) §§523 and 527 of the                   accordance with EO 11988; (e) assurance of project
    consistency with the approved State management           17. Will comply with the Laboratory Animal Welfare Act
    program developed under the Coastal Zone                     of1966 (P.L. 89-544, as amended, 7 U.S.C. §§2131 et
    Management Act of 1972 (16 U.S.C. §§1451 et seq.);           seq.)pertaining to the care, handling, and treatment of
    (f) conformity of Federal actions to State (Clean Air)       warm blooded animals held for research, teaching or
    Implementation Plans under Section 176c of the Clean         other activities supported by this award of assistance.
    air Act of 1955, as amended (42 U.S.C. §§7401 et
    seq.) (g) protection of underground sources of           18. Will comply with the Lead-Based Paint Poisoning
    drinking water under the Safe Drinking Water Act of          Prevention Act (42 U.S.C. §§4801 et seq.) which
    1974, as amended (P.L. 93-523);and, (h) protection of        prohibits the use of lead-based paint in construction or
    endangered species under the Endangered Species Act          rehabilitation of residence structures.
    of 1973, as amended (P.L. 93-205).
                                                             19. Will cause to be performed the required financial and
12. Will comply with the Wild and Scenic Rivers Act              compliance audits in accordance with the Single Audit
    of1968 (16 U.S.C. §§1271 et seq.) related to                 Act Amendments of 1966 and OMB Circular No. A-
    protecting components of potential components of the         133, “Audits of States, Local Governments, and Non-
    national wild and scenic rivers system.                      Profit Organizations.”

13. Will assist the awarding agency in assuring              20. Will make a full disclosure in writing to The
    compliance with Section 106 of the National Historic         Foundation, any corporation, partnership, sole
    Preservation Act of 1966, as amended (16 U.S.C.              proprietorship, or other business entity of any kind
    §470), EO 11593(identification and protection of             which is a wholly or partially own entity of the
    historic properties), and the Archaeological and             applicant or whose relatives supply goods or services
    Historic Preservation Act of1974 (16 U.S.C. §§469a-1         to applicant or work for or provide services to
    et seq.).                                                    applicant.

14. Will comply with P.L. 93-348 regarding the protection    21. Will certify that no entity, agency, or person
    of human subjects involved in research, development,         associated with the applicant is debarred or suspended
    and related activities supported by this award of            or is otherwise excluded from or ineligible for
    assistance.                                                  participation in federal assistance programs under
                                                                 Executive Order 12549, “Debarment and Suspension”.
15. Pursuant to 40 CFR 30.18, will comply, as
    applicable, with P.L. 101-391, the Hotel-Motel           22. Will certify that it is registered and licensed to do
    Fire Safety Act. The recipient will agree to                 business in the State it resides. The applicant and its
    ensure that all space for conferences, meetings,             employees and all sub-recipients shall be licensed
                                                                 pursuant to all applicable federal, state, and local laws,
    conventions, or training seminars funded in                  ordinances, rules, and regulations and shall upon
    whole or in part with federal funds complies with            request provide proof of all licenses.
    the protection and control guidelines of the Hotel
    and Motel Fire Safety Act. Recipients may                23. The authorized official signing for the applicant
    search the Hotel-Motel National Master List at               certifies that the statements herein are true, complete,
    http://www.usfa.dhs.gov/applications. hotel/ to              and accurate to the best of his or her knowledge, and
    see if a property is in compliance.                          that he or she is aware that any false, fictitious, or
                                                                 fraudulent statements or claims may subject him or her
16. Will certify that you as the recipient, your                 to criminal, civil, or administrative penalties. The
    employees, subrecipients under this award, and               undersigned agrees the applicant organization will
                                                                 comply with all terms and conditions of the Grant
    subrecipients’ employees will not engage in                  Agreement.
    severe forms of trafficking in persons during the
    period of time that the award is in effect; procure      24. Will comply with all applicable requirements of all
    a commercial sex act during the period of time               other Federal laws, executive orders, regulations, and
    that the award is in effect; or use forced labor in          policies governing this program.
    the performance of the award or subawards
    under the award.


 APPLICANT ORGANIZATION                                        DATE SUBMITTED

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