**Department of Health and Human Services**

*Administration on Aging*

**CERTIFICATIONS REGARDING DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTERS, DRUG-FREE WORKPLACE REQUIREMENTS AND LOBBYING**

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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 45CFR Part 76,
\"Government Debarment and Suspension (Non-procurement)\" and
\"Government wide Requirements for Drug-Free Workplace\" and 45CFR Part
93. \"New Restrictions on Lobbying.\" The certifications shall be
treated as a material representation of fact upon which reliance will be
placed when the Administration on Aging determines to award the covered
transaction, grant, or cooperative agreement.

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*1. Debarment, Suspension, and Other Responsibility Matters*

As required by Executive Order 12549, Debarment and Suspension, and
implemented at 45 CFR Part 76, for prospective participants in primary
covered transactions, as defined at 45 CFR Part, 76, Sections 76.105 and
76.110 -

\(1\) The prospective primary participant certifies to the best of its
knowledge and belief, that it and its principals:

\(a\) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded by any Federal department
or agency;

\(b\) Have not within a three-year period preceding this proposal been
convicted of or had a civil judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing 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 governmental 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/proposal had one or more public transactions (Federal, State
or local) terminated for cause or default.

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

*2. Certification Regarding Drug-Free Workplace Requirements*

*Alternate I. (Grantees Other Than Individuals)*

As required by the Drug-Free Workplace Act of 1988, and implemented at
45 CFR Part 76, Subpart F, for grantees, as defined at 45 CFR Part 76,
Sections 76.605 and 76.610 -

A. The grantee certifies that it will or 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 ongoing drug-free awareness program to inform
employees about \--

(1)The dangers of drug abuse in the workplace;

\(2\) The grantee\'s 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 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 employer 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 ten calendar days after
receiving notice under paragraph (d)(2) from an employee or otherwise
receiving actual notice of such conviction. Employers of convicted
employees must provide notice, including position title, to: Director,
Office of Grants Management and Policy, ASAM, Department of Health and
Human Services, Room 336-E, HHH Building, 200 Independence Avenue, S.W.,
Washington, D.C. 20201. Notice shall include the identification
number(s) of each affected grant;

\(f\) Taking one of the following actions, within 30 calendar days of
receiving notice under paragraph (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:

Place of Performance (Street address, city, county, state, zip code)

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  Place of Performance:

  Address:

  Address:

  City:

  State:

  Zip Code:

  County:
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Check if there are workplaces on file that are not identified here.

Alternate II. (Grantees Who Are Individuals)

As required by the Drug-Free Workplace Act of 1988, and implemented at
45 CFR Part 76, Subpart F, for grantees, as defined at 45 CFR Part 76,
Sections 76.605 and 76.610

\(A\) The grantee certifies that, as a condition of the grant, he or she
will not engage in the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance in conducting any activity
with the grant;

\(B\) If convicted of a criminal drug offense resulting from a violation
occurring during the conduct of any grant activity, he or she will
report the conviction, in writing, within 10 calendar days of the
conviction, to: Director, Office of Grants Management and Policy, ASAM,
Department of Health and Human Services, Room 336-E, HHH Building, 200
Independence Avenue, S.W., Washington, D.C. 20201. When notice is made
to such a central point, it shall include the identification number(s)
of each affected grant.

3\. LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

As required by Section 1352, Title 31 of the U.S. Code, and implemented
at 45 CFR Part 93, for persons entering into a grant, cooperative
agreement or contract over \$100,000, or loan, or loan guarantee over
\$150,000, as defined at 45 CFR Part 93, Sections 93.105 and 93.110 the
applicant certifies that to the best of his or her knowledge and belief,
that:

1.  \(1\) 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 certification is a material representation of fact
    upon which reliance was placed when this 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 sub-awards at
all tiers (including subcontracts, sub-grants, and contracts under
grants, loans, and cooperative agreements) and that all sub-recipients
shall certify and disclose accordingly. 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.

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.

Statement for Loan Guarantees and Loan Insurance

The undersigned states, to the best of his or her knowledge and belief,
that:

If any 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 commitment
providing for the United States to insure or guarantee a loan, the
undersigned shall complete and submit Standard Form-LLL, \`\`Disclosure
Form to Report Lobbying,\'\' in accordance with its instructions.

Submission of this statement 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 statement shall be subject to a
civil penalty of not less than \$10,000 and not more than \$100,000 for
each such failure.

As the duly authorized representative of the applicant, I hereby certify
that the applicant will comply with the above applicable
certification(s).

NAME OF APPLICANT

AWARD NUMBER AND/OR PROJECT NAME

SIGNATURE

DATE