**[ADDITIONAL ASSURANCES]{.underline}**

**CERTIFICATIONS**

 

> **1. CERTIFICATION REGARDING DRUG-FREE WORK-PLACE REQUIREMENTS**

The undersigned (authorized official signing for the applicant
organization) certifies that it will provide a drug-free workplace in
accordance with the Drug-Free Workplace Act of 1988, 20 CFR Part 436,
subpart F.

The certification set out below is a material representation of fact
upon which reliance will be placed when SSA determines to award the
grant. If it is later determined that the grantee knowingly rendered a
false certification, or otherwise violates the requirements of the
Drug-Free Workplace Act, SSA, in addition to any other remedies
available to the Federal Government, may take action authorized under
the Drug-Free Workplace Act. False certification or violation of the
certification shall be grounds for suspension of payments, suspension or
termination of grants or governmentwide suspension or debarment.

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) above;
>
> \(d\) Notifying the employee in the statement required by paragraph
> (a), above, 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 within ten calendar days after receiving
> notice under subparagraph (d)(2), above, from an employee or otherwise
> receiving actual notice of such conviction. Employers of convicted
> employees must provide notice, including position title, to every
> grant officer or other designee on whose grant activity the convicted
> employee was working, unless the Federal agency has designated a
> central point for the receipt of such notices.
>
> Notices shall include the identification number(s) of each affected
> grant;
>
> \(f\) Taking one of the following actions, within 30 days of receiving
> notice under subparagraph (d)(2), above, 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), above.

The grantee certifies that, as a condition of the grant, it will not
engage in the unlawful manufacture, distribution, dispensing, possession
or use of a controlled substance in conducting any activity with the
grant.

 

> **2. CERTIFICATION REGARDING LOBBYING**

Title 31, United States Code, Section 1352, entitled \"Limitation on use
of appropriated funds to influence certain Federal contracting and
financial transactions,\" generally prohibits recipients of Federal
grants and cooperative agreements from using Federal (appropriated)
funds for lobbying the Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant or cooperative agreement.
Section 1352 also requires that each person who requests or receives a
Federal grant or cooperative agreement must disclose lobbying undertaken
with non-Federal (non-appropriated) funds. These requirements apply to
grants and cooperative agreements EXCEEDING \$100,000 in total costs (20
CFR Part 438).

The undersigned (authorized official signing for the applicant
organization) certifies, to the best of his or her knowledge and belief,
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 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.
>
> \(b\) If any funds other then Federally 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 of Lobbying Activities,\" in
> accordance with its instructions. (If needed, Standard Form-LLL,
> \"Disclosure of Lobbying Activities,\" its instructions, and
> continuation sheet are included at the end of this application form.)
>
> \(c\) 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.\"

 

> **3. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
> RESPONSIBILITY MATTERS**

NOTE: In accordance with 20 CFR Part 436, amended June 26, 1995, any
debarment, suspension, proposed debarment or other governmentwide
exclusion initiated under the Federal Acquisition Regulation (FAR) on or
after August 25, 1995, shall be recognized by and effective for
Executive Branch agencies and participants as an exclusion under 20 CFR
Part 436.

> \(a\) **Primary Covered Transactions**
>
> The undersigned (authorized official signing for the applicant
> organization) certifies to the best of his or her knowledge and
> belief, that the applicant, defined as the primary participant in
> accordance with 20 CFR Part 436, and its principals:
>
> \(1\) are not presently debarred, suspended, proposed for debarment,
> declared ineligible, or voluntarily excluded by any Federal department
> or agency;
>
> \(2\) have not within a 3-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;
>
> \(3\) 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 (a)(2)
> of this certification; and
>
> \(4\) have not within a 3-year period preceding this
> application/proposal had one or more public transactions (Federal,
> State, or local) terminated for cause or default.

Should the applicant not be able to provide this certification, an
explanation as to why should be placed under the assurances page in the
application package.

 

> \(b\) **Lower Tier Covered Transactions**

The applicant agrees by submitting this proposal that it will include,
without modification, **the following clause titled [\"Certification
Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
\-- Lower Tier Covered Transaction\"]{.underline}** (Appendix B to 20
CFR Part 436) in all lower tier covered transactions (i.e., transactions
with subgrantees and/or contractors) and in all solicitations for lower
tier covered transactions:

**Certification Regarding Debarment, Suspension, Ineligibility, and
Voluntary Exclusion \-- Lower Tier Covered Transactions**

> \(1\) The prospective lower tier participant certifies by submission
> of this proposal, that neither it nor its principals is 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 lower tier participant is unable to
> certify to any of the statements in this certification, such
> prospective participant shall attach an explanation to this proposal.

+------------------------------------------+-------+------------------+
| SIGNATURE OF AUTHORIZED CERTIFYING       | TITLE |                  |
| OFFICIAL                                 |       |                  |
|                                          |       |                  |
+------------------------------------------+-------+------------------+
| APPLICANT ORGANIZATION                   |       | DATE SUBMITTED   |
|                                          |       |                  |
|                                          |       |                  |
+------------------------------------------+-------+------------------+