Contract Assurances by na9tkUr5

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									            Contract Assurances
                              for

Refugee Targeted Assistance Grant/ Formula Contracts

                         Required by the

                    City of Worcester
                             and the

        Mass Office for Refugees and Immigrants

                 RFP Released December 15, 2011
    CERTIFICATION OF COMPLIANCE WITH MASSACHUSETTS TAX LAWS



Pursuant to M.G.L. c. 62C, s. 49A, I certify under the penalties of perjury that I have complied with all
                        laws of the Commonwealth relating to taxes.




__________________________________                  __________________________________
Social Security Number or Federal                   Signature of Individual or Corporate Name
Identification Number




________________________________                    BY_______________________________
Street and Number                                     Corporate Officer (if applicable)




________________________________                    ________________________________
City or Town                                        Date




________________________________
State




________________________________
Zip Code
                              CERTIFICATION OF COMPLIANCE WITH
                               WORCESTER REVISED ORDINANCES
                               GOVERNING REVENUE COLLECTION

        Pursuant to M.G.L.c. 40, section 57 and Worcester Revised Ordinances, Chapter 11, Article 2,
   Section 1, et. seq., I hereby certify, under the pains and penalties of perjury, that the undersigned
   applicant, and all parties having an ownership interest therein, have complied with the laws of the
 Commonwealth of Massachusetts and the City of Worcester regarding payment of all local taxes, fees,
                  assessments, betterments or any other municipal charges of any kind.



GIVE FULL NAMES AND RESIDENCES OF ALL PERSONS AND PARTIES INTERESTED IN

THIS APPLICATION

(Give first and last name in full; in case of a corporation give names of President, Treasurer and
Manager; and in case of firms, give names of individual members).

(1)     If a Proprietorship

Name of Owner          ______________________________________

Business address       ______________________________________

                       ______________________________________

Home Address           ______________________________________

Business Phone         ____________           Home Phone ____________

(2)     If a Partnership

Full names and addresses of all partners

Names                                 Addresses

_________________________             __________________________________

_________________________             __________________________________

_________________________             __________________________________

_________________________             __________________________________

Business Address       ____________________________________________

Business Phone         ____________________________


                                                                                    p. 1 of 3
(3)    If a Corporation

Full legal name      ______________________________________

State of incorporation ______________________________________



Principle place of business _________________________________________

Place of business in Massachusetts ___________________________________

Officers of Corporation

Name                                          Title

______________________________                ___________________________

______________________________                ___________________________
______________________________                ___________________________

______________________________                ___________________________

Owners of Corporation

Name                                          Title

_____________________________                 ___________________________

_____________________________                 ___________________________

_____________________________                 ___________________________

_____________________________                 ___________________________

(4)    If a trust

Name of Trust ___________________________________________________

Business Address ________________________________________________

Name of Trustees                       Address

________________________________       ___________________________________

________________________________       ___________________________________

________________________________       ___________________________________

________________________________       ____________________________________

                                                                         p.2 of 3




Names of Beneficiaries                 Address
________________________________         ___________________________________

________________________________         ___________________________________

________________________________         ___________________________________

________________________________         ___________________________________



Dated this    day of

By Name _____________________________________________

    Title _____________________________________________

    Business Address _________________________________________________

Social Security or Federal I.D. No. ______________________




                                                                       p. 3 of 3



                        SIGNATORY AUTHORIZATION
                        FOR CORPORATE PROVIDERS
                                                               PART A

PROVIDER:________________________________________________________________________________

ADDRESS:_________________________________________________________________________________

CITY/STATE/ZIP:      ___________________________________________________________________________


Complete all sections:
                                MASSACHUSETTS OR FOREIGN CORPORATION

       O     Massachusetts Corporation                  O     Non-Massachusetts Corporation

    A non-Massachusetts corporation is required to register with the Massachusetts Secretary of State to obtain an authorization to do
    business within Massachusetts. Attach a copy of such authorization to this form.

                                                CORPORATE TAX STATUS

O     For-Profit Corporation     O     Corporation exempt from taxation under 501 (C) (3)        O      Corporation exempt from
                                          of the Internal Revenue Code.                                  taxation under ___________
                                                                                                        of the Internal Revenue Code.

                                                  CERTIFICATE OF VOTE

    The following statement must be completed and signed by the Clerk(s) of the corporation, or a Certificate of Vote authorizing a
    signator to execute contracts on behalf of the corporation must be attached.

   At a duly authorized meeting of the Board of Directors of ________________________________________________________

   (Name of Corporation) held on _______________________(Date), in accordance with the by-laws of said corporation, it was
   voted that

   _________________________________________________ _________________________________________and/or
     Name                                               Title

   _________________________________________________ _________________________________________and/or
      Name                                                               Title
  of the corporation be hereby authorized to execute contracts and bonds on behalf of the corporation and that such execution of any
  contract or obligation in this corporation's name on its behalf by the person authorized shall be valid and binding o this corporation.

  Signature of Clerk:_______________________________________________ Date:__________________________

                                              AFFIDAVIT OF COMPLIANCE
I, ______________________________, authorized signator of _______________________________ (name of corporation) do
hereby certify that the above named corporation has filed with the Secretary of State all certificates and reports required by MGL
c.156B s. 109 and MGL c. 181 s. 4 or MGL c.180 s. 26A.

                                                                PART B

         SIGNATORY AUTHORIZATION
         FOR NON-CORPORATE PROVIDERS

         PROVIDER:__________________________________________________________________
ADDRESS:___________________________________________________________________

CITY/STATE/ZIP:_____________________________________________________________

Complete one of the following sections:
                                                 PARTNERSHIP
List the names and addresses of all partners as of _____________________________, 19_________:

         Name _______________________________________________
         Address ________________________________________________

         Name _______________________________________________
         Address ________________________________________________

         Name _________________________________________________
         Address ________________________________________________


O      Limited Partnership: The general partner authorized to sign is:
________________________________________________
O        General Partnership: All partners have the authority to sign and bind the partnership.

O        General Partnership: In accordance with a written partnership agreement dated
_______________________________, the partner ______________________________ has the authority to sign
contracts.

                                                       TRUST

 List the names and addresses of all trustees and identify which trustee(s) is authorized signator as of
_____________, 19 ______:

         Name _______________________________________________
         Address ________________________________________________

         Name _______________________________________________
         Address ________________________________________________

         Name _________________________________________________
         Address ________________________________________________


                             MUNICIPAL OR COUNTY GOVERNMENT
O        A contract must be signed by; all members of the board or commission or by the chief executive authorized
by statute to make contracts, or such authorization may be delegated to an employee. A copy of this delegation of
authority must be attached to this form. Delegated authorization is effective __________________________,
19________.

                                          SOLE PROPRIETORSHIP
O        If your business is not a corporation, partnership, trust, or government body, it is a sole proprietorship. A
sole proprietorship must sign all contracts awarded to him/her.
                  CERTIFICATION REGARDING DEBARMENT
                                              PART A

             SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION:
                     LOWER TIER COVERED TRANSACTIONS


        This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The
regulations were published as Part VII of the MAY 26, 1988 Federal Register (pages 19160-
19211).

        (Before Completing Certification, Read Attached Instructions Which Are an Integral Part
of the Certification)

(1)    The prospective recipient of Federal assistance funds certifies, by submission of this
proposal, that neither it nor its principals are presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this transaction by
any Federal department or agency.


(2)     Where the prospective recipient of Federal assistance funds is unable to certify to any of
the statements in this certification, such prospective participant shall attach an explanation to this
proposal.




______________________________________________________________________________
Grantee/Contractor Organization                                    Program/Title



______________________________________________________________________________
Name and Title of Authorized Signatory



______________________________________________________________________________
Signature                                                                 Date
                                       PART B
                            INSTRUCTIONS FOR CERTIFICATION


(1)     By signing and submitting this proposal, the prospective recipient of Federal assistance
funds is providing the certification as set out below.

(2)     The certification in this clause is a material representation of fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the prospective
recipient of Federal assistance funds knowingly rendered an erroneous certification, in addition
to other remedies available to the Federal Government, the Department of Labor (DOL) may
pursue available remedies, including suspension and/or debarment.

(3)     The prospective recipient of Federal assistance funds shall provide immediate written
notice to the person to which this proposal is submitted if at any time the prospective recipient of
Federal assistance funds learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstance.

(4)     The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier
covered transaction", "principal", "proposal", and "voluntarily excluded", as used in this clause,
have the meanings set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the person to which this proposal is submitted for
assistance in obtaining a copy of those regulations.

(5)     The prospective recipient of Federal assistance funds agrees by submitting this proposal
that, should the proposed covered transaction be entered into, it shall not knowingly enter into
any lower tier covered transaction with a person who is debarred, suspended, declared ineligible,
or voluntarily excluded from participation in this covered transaction, unless authorized by the
DOL.

(6)      The prospective recipient of Federal assistance funds further agrees by submitting this
proposal that it will include the clause titled "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion-Lower Tier Covered Transactions", without modification,
in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

(7)      A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or
voluntarily excluded from the covered transaction, unless it knows that the certification is
erroneous. A participant may decide the method and frequency by which it determines the
eligibility of its principals. Each participant may but is not required to check the List of Parties
Excluded from Procurement or Nonprocurement Programs.
                                         PART B (cont.)

(8)    Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.

(9)     Except for transactions authorized under paragraph 5 of these instructions, if a participant
in a covered transaction knowingly enters into a lower tier covered transaction with a person who
is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction,
in addition to other remedies available to the Federal Government, the DOL may pursue
available remedies, including suspension and/or debarment.
                     CERTIFICATION REGARDING LOBBYING
                  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* subrecipients 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.

______________________________________________________________________________
Grantee/Contractor Organization                         Program/Title

______________________________________________________________________________
Name and Title of Authorized Signatory

______________________________________________________________________________
Signature                                              Date

*Note: In these instances, "All" in the Final Rule is expected to be clarified to show that it
applies to covered contract/grant transactions over $100,000 (per OMB).
                EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION
                       NON-DISCRIMINATION POLICY STATEMENT


______________________________________________________________________________
                                                    (Name of Organization)
has a statutory mandate under law to guarantee equal treatment for all who seek access to its services or
opportunities for employment and advancement. No discrimination will be tolerated on the basis of race, creed,
political affiliation, color, sex, national origin, age, handicap or veteran status. The ultimate goal is for personnel of
this organization to reflect the proportion of minority, female, Vietnam era veteran and handicapped persons in the
populations they serve.


____________________________________________________________________________________________
                                               (Name of Organization)
will meet its legal, moral, social and economic responsibilities for Equal Employment Opportunity/Affirmative
Action as authorized and required by all pertinent state and federal legislation, executive orders and rules and
regulations, including the following:

 1. Title VII of the Civil Rights Act of 1964 as amended by the Equal Employment Opportunity Act of 1972
    (42USC s2000e et seq.), which prohibits discrimination in employment on the basis of race, color, religion, sex
     or national origin; and

 2. The Age Discrimination in Employment Act of 1967 (29 USC s621 et seq.), which prohibits discrimination in
    employment on the basis of age with regard to those individuals who are at least 40 years of age, but less than
    65 years of age; and

 3. Section 504 of the Rehabilitation Act of 1973 (29 USC s794), and the regulations promulgated pursuant thereto
    (45 CFR Part 84), which prohibit discrimination against qualified handicapped individuals on the basis of
     handicap and requires employers to make reasonable accommodations to known physical or mental limitations
     of otherwise qualified handicapped applicants and employees; and

 4. M.G.L. c.151B s4 (1), as amended by Chapter 533, 1983, which prohibits discrimination in employment on the
    basis of race, color, sex, religious creed, national origin, ancestry, age or handicap.

    In addition, the Provider agrees to be familiar with and abide by:

    .   Massachusetts Executive Order 227, (Governor's Code of Fair Practices, 1983), amending and revising
    Executive Order No. 74; as amended by Executive Orders Nos. 116 and 117.

    .    Massachusetts Executive Order 246, revoking and superseding Executive Order Nos. 143 and 150.

    .  Massachusetts Executive Order 253, amending and revising Executive Order No. 235, revising and
    amending Executive Order Nos. 74, 224 and 227.

    .    Executive Order No. 240 revising and amending Executive Order No. 200.

    .    Massachusetts Architectural Barriers Board Act.

    .    Federal Executive Orders 11246 and 11375 as amended.

All employees, unions, subcontractors, and vendors must make genuine and consistent efforts:

    1. to ensure equal employment opportunities for present and future employees, and;
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    2. to implement affirmative action, as legally required, to remedy the effects of past employment
        discrimination and social inequalities.

The responsibility for implementing and monitoring this policy has been delegated to

______________________________________________________________________________
     (Name and title of employee)

Furthermore,_________________________________________________________________________
                             (Name of organization)
prohibits that any employee, or applicant, be subjected to coercion, intimidation, interference, or discrimination for
filing a complaint or assisting in an investigation under this program. No portion of this Equal Employment
Opportunity/Affirmative Action Non-Discrimination Policy shall be construed as conflicting with any existing or
future judicial or legislative mandate where a construction consistent with that mandate is reasonable.

All Operating Agencies awarded contracts are required to submit an EEO/AA plan to the City in accordance with
requirements established in this agreement.


________________________________________________________________________________________
                                              (Name of Organization)
agrees to the terms and conditions of this EEO/AA Non-Discrimination Policy Statement.



                                                       _______________________________________________
                                                       Signature of Chief Executive Officer


                                                       _______________________________________________
                                                       Title of Chief Executive Officer


                                                       _______________________________________________
                                                       Date




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