HomeMy WebLinkAbout2011-408 DSS - NC Dept. of Health and Human Services Contract Contract#00024238
This contract is hereby entered into by and between the North Carolina Department of Health and Human Services,Office of
the Secretary(the"Division")and Orange County(the"Contractor")(referred to collectively as the"Parties"). The Contractor's
federal tax identification number is 56-6000327.
1. Contract Documents:
This Contract consists of the following documents:
(1) This contract
(2) The General Terms and Conditions(Attachment A)
(3) The Scope of Work, description of services, or Contractor's proposal (Attachment B)
(4) The line item budget and budget narrative (Attachment C)and if applicable, indirect cost documentation
(5) Conflict of Interest(Attachment D)and copy of Contractor's conflict of interest policy
(6) Consolir#ated Federal.Certifications (Envifonmentaf Tobacco Smoke; Lobbying;,Debarment; Drug-Free Workplace)
(Attachment E)
These documents constitute the entire agreement between the Parties and supersede all prior oral or written statements
or agreements.
2. Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents,the terms in the Contract Document with
the highest relative precedence shall prevail. The order of precedence shall be the order of documents as listed in
Paragraph 1,above,with the first-listed document having the highest precedence and the last-listed document having the
lowest precedence. If there are multiple Contract Amendments, the most recent amendment shall have the highest
precedence and the oldest amendment shall have the lowest precedence.
3. Effective Period:
This contract shall be effective on November 15,2010 and shall terminate on June 30, 2011,with the option to extend, if
mutually agreed upon,through a written amendment as provided for in the General Terms and Conditions as described in
Attachment A.
4. Contractor's Duties:
The Contractor shall provide the services as described in Attachment B and in accordance with the approved budget in
Attachment C.
5. Division's Duties:
The Division shall pay the Contractor in the manner and in the amounts specified in the Contract Documents. The total
amount paid by the Division to the Contractor under this contract shall not exceed$2,300.00. This amount consists of$
0.0 in State funds and$ 2,300.00 in SSBG (CFDA#93.667).
[ X ] a. There are no matching requirements from the Contractor.
[ ] b. The Contractor's matching requirement is$ , which shall consist of:
[ ] In-kind [ ] Cash
[ ] Cash and In-kind [ ]Cash and/or In-kind
The contributions from the Contractor shall be sourced from non-federal funds.
The total contract amount is$2,300.00.
6. Conflict of Interest Policy:
The Division has determined this contract is a purchase of service contract with a non profit agency. Contractor shall file
with the Division a copy of the Contractor's policy addressing conflicts of interest that may arise.The policy shall be filed
before the Division will disburse the funds. Refer to Attachment D.
NCDHHS GCT1007 (Contract) (General) (10/22/09) Page 1 of 3
7. Reporting Requirements:
The Division has determined that this is a contract for purchase of goods and services, and therefore is exempt from the
reporting requirements of N.C.G.S. § 143C-6-22 &23.
8. Payment Provisions:
Payment shall be made in accordance with the Contract Documents as described in the Scope of Work,
Attachment B.
9. .Contract Administrators:
All notices permitted or required to be given by one Party to the other and all questions about the contract from one Party
to the other shall be addressed and delivered to the other Party's Contract Administrator. The name,post office address,
street address,telephone number,fax number,and email address of the Parties'respective initial Contract Administrators
are set out below. Either Party may change the name,post office address,street address,telephone number,fax number,
or email address of its Contract Administrator by giving timely written notice to the other Party.
For the Division:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Martha Are, Homeless Policy Specialist Martha Are, Homeless Policy Specialist
Office of the Secretary Office of the Secretary
2001 MSC 101 Blair Drive
Raleigh, NC 27699
Raleigh, NC 27699-2001
Telephone 919-855-4994
Fax 919-715-4645
Email: Martha.Are@dhhs.nc.gov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Jamie Rohe Same
P.O. Box 8181
Hillsborough, NC 27278
Telephone 828-259-5851
Fax 828-350-0048
Email asawyer@ashevillenc.gov
10. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of this agreement.
11. Executive Order#24
N.C.G.S. §133-8 2 and Executive Order 24 prohibit the offer"to�or acceptance,by, ony State Employee of any gift from
anyone wath a contract with the State, or from any.person seeking to do business.with the State, sy execution of any
response in,this procurement, you"attest, for your entire organization aid its employees or agents, that you are not
aware that any such.lift has;:=been offered, accepted;or promised by ariy employees',6 your organization."
NCDHHS GCT1007 (Contract) (General) (10/22/09) Page 2 of 3
In Witness Whereof,the Contractor and the Division have executed this contract in duplicate originals,with one original being
retained by each party.
Orange County
Signature 1. Date
Printed Name gitle
WITNESS
Signature Da et
Printed Name Title
Office of the Secretary, North Carolina Department of Health and Human Services
Signature Date
Printed Name Title
NCDHHS GCT1007(Contract) (General) (10/22/09) Page 3 of 3
Attachment A
General Terms and Conditions
Relationships of the Parties and any of their officers, agents and employees, from any
claims of third parties arising out of any act or omission of
Independent Contractor: The Contractor is and shall be the Contractor in connection with the performance of this
deemed to be an independent contractor in the contract to the extent permitted by law.
performance of this contract and as such shall be wholly
responsible for the work to be performed and for the Default and Termination
supervision of its employees. The Contractor represents
that it has,or shall secure at its own expense,all personnel Termination Without Cause: The Division may terminate
required in performing the services under this agreement. this contract without cause by giving 30 days written notice
Such employees shall not be employees of, or have any to the Contractor,
individual contractual relationship with, the Division.
Termination for Cause: If, through any cause, the
Subcontracting: The Contractor shall not subcontract Contractor shall fail to fulfill its obligations under this
any of the work contemplated under this contract without contract in a timely and proper manner, the Division shall
prior written approval from the Division. Any approved have the right to terminate this contract by giving written
subcontract shall be subject to all conditions of this notice to the Contractor and specifying the effective date
contract. Only the subcontractors specified in the contract thereof. In that event,all finished or unfinished deliverable
documents are to be considered approved upon award of items prepared by the Contractor under this contract shall,
the contract. The Division shall not be obligated to pay for at the option of the Division, become its property and the
any work performed by any unapproved subcontractor. Contractor shall be entitled to receive just and equitable
The Contractor shall be responsible for the performance of compensation for any satisfactory work completed on such
all of its subcontractors. materials,minus any payment or compensation previously
made. Notwithstanding the foregoing provision, the
Assignment: No assignment of the Contractor's Contractor shall not be relieved of liability to the Division
obligations or the Contractor's right to receive payment for damages sustained by the Division by virtue of the
hereunder shall be permitted. However, upon written Contractor's breach of this agreement, and the Division
request approved by the issuing purchasing authority,the may withhold any payment due the Contractor for the
State may: purpose of setoff until such time as the exact amount of
(a) Forward the Contractor's payment check(s) . damages due the Division from such breach can be
directly to any person or entity designated by the determined. In case of default by the Contractor, without
Contractor, or limiting any other remedies for breach available to it, the
(b) Include any person or entity designated by Division may procure the contract services from other
Contractor as a joint payee on the Contractor's sources and hold the Contractor responsible for any
payment check(s). excess cost occasioned thereby. The filing of a petition for
In no event shall such approval and action obligate the bankruptcy by the Contractor shall be an act of default
State to anyone other than the Contractor and the under this contract.
Contractor shall' remain responsible for fulfillment of all
contract obligations. Waiver of Default:Waiver by the Division of any default or
breach in compliance with the terms of this contract by the
Beneficiaries: Except as, herein specifically provided Contractor shall not be deemed a waiver of any
otherwise,this contract shall inure to the benefit of and be subsequent default or breach and shall not be construed to
binding upon the parties hereto and their respective be modification of the terms of this contract unless stated
successors. It is expressly understood and agreed that the to be such in writing, signed by an authorized
enforcement of the terms and conditions of this contract, representative of the Department and the Contractor and
and all rights of action relating to such enforcement, shall attached to the contract.
be strictly reserved to the Division and the named
Contractor. Nothing contained in this document shall give
or allow any claim or right of action whatsoever by any Availability of Funds: The parties to this contract agree
other third person. It is the express intention of the Division and understand that the payment of the sums specified in
and Contractor that any such person or entity, other than this contract is dependent and contingent upon and subject
the Division or the Contractor, receiving services or to the appropriation,allocation,and availability of funds for
benefits under this contract shall be deemed an incidental this purpose to the Division.
beneficiary only.
Force Majeure: Neither party shall be deemed to be in
Indemnity and Insurance default of its obligations hereunder if and so long as it is
prevented from performing such obligations by any act of
Indemnification: The Contractor agrees to indemnify and war, hostile foreign action, nuclear explosion, riot, strikes,
hold harmless the Division, the State of North Carolina,
NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10/22/09) Page 1 of 3
civil insurrection, earthquake, hurricane,tornado, or other
catastrophic natural event or act of God. Executive,Qrder 24 also encouraged and invited other
State Agencies,. implement the requirements and
Survival of Promises: All promises,requirements,terms, prohibitions of�the�Executive or( es'.
agencies
conditions, provisions, representations, guarantees, and Vendors and-cdhtractors should contact ottaer.State
warranties contained herein shall survive the contract Agencres to determine i thoseagencies.have adopted
expiration or termination date unless specifically provided Executive:Order 24:"
otherwise herein, or unless superseded by applicable
Federal or State statutes of limitation.
Intellectual Property Rights Confidentiality
Copyrights and Ownership of Deliverables: All Confidentiality: Any information, data, instruments,
deliverable items produced pursuant to this contract are documents, studies or reports given to or prepared or
the exclusive property of the Division. The Contractor shall assembled by the Contractor under this agreement shall
not assert a claim of copyright or other property interest in be kept as confidential and not divulged or made available
such deliverables. to any individual or organization without the prior written
approval of the Division.The Contractor acknowledges that
Compliance with Applicable Laws in receiving, storing, processing or otherwise dealing with
any confidential information it will safeguard and not further
Compliance with Laws: The Contractor shall comply with disclose the information except as otherwise provided in
all laws, ordinances, codes, rules, regulations, and this contract.
licensing requirements that are applicable to the conduct of Oversight
its business, including those of federal, state, and local
agencies having jurisdiction and/or authority. Access to Persons and Records:The State Auditor shall
have access to persons and records as a result of all
Equal Employment Opportunity: The Contractor shall contracts or grants entered into by State agencies or
comply with all federal and State laws relating to equal political subdivisions in accordance with General Statute
employment opportunity. 147-64.7. Additionally, as the State funding authority, the
Department of Health and Human Services shall have
Health Insurance Portability and Accountability Act access to persons and records as a result of all contracts
(HIPAA): The Contractor agrees that, if the Division or grants entered into by State agencies or political
determines that some or all of the activities within the subdivisions.
scope of this contract are subject to the Health
Insurance Portability and Accountability Act of 1996, P.L. Record Retention: Records shall not be destroyed,
104-91, as amended ("HI PAN"), or its implementing purged or disposed of without the express written consent
regulations, it will comply with the HIPAA requirements of the Division. State basic records retention policy
and will execute such agreements and practices as the requires all grant records to be retained for a minimum of
Division may require to ensure compliance. five years or until all audit exceptions have been resolved,
whichever is longer. If the contract is subject to Federal
Executive;Order#24: "By Executive Order 24, issued policy and regulations,record retention may be longer than
by Governor Perdue;and N.C:G.S.§J 33=32,`ifls five years since records must be retained for a period of
unlawful for any vendor or contractor( .e. architect; three years following submission of the final Federal
bidder, contractor; construction.manager, design. Financial Status Report, if applicable, or three years
professional, engineer, landlord; offero.t, seller; following the submission of a revised final Federal
subcontractor;suppflen or vendor, to i ake gifts or to Financial Status Report. Also, if any litigation, claim,
give favors to any St, e employee f the Goarerrior's negotiation, audit, disallowance action, or other action
Cabinet Agencies(i.e., Adrriinistratian,'Comm�erce, involving this Contract has been started before expiration
Correction'. Crime`Control and Public Safety, Cultural of the five-year retention period described above, the
Resources, Environment;and,Natural Resources, Health records must be retained until completion of the action and
and Human Services, Juvenile Justice'and Delinquency resolution of all issues which arise from it, or until the end
Prevention, Revenue, Transportation, and the Office of of the regular five-year period described above,whichever
the_Governor).. This'prQtibitionooversahose vendors is later.
and contractors-rho have a;contract with a
governmental agency ar h ve performed°under such a
ca ntractwith1nthe past year; or anticipate°bidding on
such a contract in the future;
For'additional information regarding the specific
requirements and exemptions, vendors and contractors
are encouraged to-review Executive.Order.24'an, G S
See 1.33-32.
NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 10/22/09) Page 2 of 3
Miscellaneous
Time of the Essence: Time is of the essence in the
Choice of Law: The validity of this contract and any of its performance of this contract.
terms or provisions, as well as the rights and duties of the
parties to this contract, are governed by the laws of North Key Personnel: The Contractor shall not replace any of
Carolina.The Contractor, by signing this contract, agrees the key personnel assigned to the performance of this
and submits,solely for matters concerning this Contract,to contract without the prior written approval of the Division.
the exclusive jurisdiction of the courts of North Carolina The term "key personnel' includes any and all persons
and agrees, solely for such purpose, that the exclusive identified as such in the contract documents and any other
venue for any legal proceedings shall be Wake County, persons subsequently identified as key personnel by the
North Carolina. The place of this contract and all written agreement of the parties.
transactions and agreements relating to it, and their sites
and forum, shall be Wake County, North Carolina, where Care of Property: The Contractor agrees that it shall be
all matters,whether sounding in contract or tort,relating to responsible for the proper custody and care of any
the validity, construction, interpretation, and enforcement property furnished to it for use in connection with the
shall be determined. performance of this contract and will reimburse the Division
for loss of,or damage to,such property.At the termination
Amendment: This contract may not be amended orally or of this contract,the Contractor shall contact the Division for
by performance. Any amendment must be made in written instructions as to the disposition of such property and shall
form and executed by duly authorized representatives of comply with these instructions.
the Division and the Contractor. The Purchase and
Contract Divisions of the NC Department of Administration Travel Expenses: Reimbursement to the Contractor for
and the NC Department of Health and Human Services travel mileage, meals, lodging and other travel expenses
shall give prior approval to any amendment to a contract incurred in the performance of this contract shall not
awarded through those offices. exceed the rates published in the applicable State rules or
approved local government travel policy. International
travel shall not be reimbursed under this contract.
Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of this Sales/Use Tax Refunds: If eligible,the Contractor and all
contract violates any applicable law, each such provision subcontractors shall: (a) ask the North Carolina
or requirement shall continue to be enforced to the extent it Department of Revenue for a refund of all sales and use
is not in violation of law or is not otherwise unenforceable taxes paid by them in the performance of this contract,
and all other provisions and requirements of this contract pursuant to G.S. 105-164.14; and (b) exclude all
shall remain in full force and effect. refundable sales and use taxes from all reportable
expenditures before the expenses are entered in their
Headings: The Section and Paragraph headings in these reimbursement reports.
General Terms and Conditions are not material parts of the
agreement and should not be used to construe the
meaning thereof.
Advertising: The Contractor shall not use the award of
this contract as a part of any news release or commercial
advertising.
NCDHHS TC1010 (General Terms and-Conditions) (Local Government) (Rev. 10/22/09) Page 3 of 3
Orange County
Contract#.-00024238
ATTACHMENT B
A. Needs Assessment
There are over 10,000 homeless people on any given night in North Carolina. Current projects of
the ICCHP include supporting local communities engaged in developing and implementing 10 Year
Plans to End Homelessness or 10 Year Plans to End Chronic Homelessness. There are over 200
homeless people in Orange County on any given night. Effective plan implementation requires
establishing baselines and evaluating outcomes.
B. Purpose
Contractor is expected to provide established data about homelessness in Orange County.
Contractor is not expected to cover the entire cost of collecting identified data with the contract
from the ICCHP. Contractor is encouraged to use contract funds to leverage local funds used to
gather information identified in this RFA.
C. Project Methods/Design
The contractor is responsible for submitting the following report:
10 Year Plan Accomplishment Report for calendar year 2010, with a cover letter from mayor and/or
county chair, depending on which jurisdiction(s) are endorsing the 10 year planning process.
Deliverable: Submit Accomplishment Report reflecting calendar year 2010 data, by May 15,
2011.
Estimated Number of Hours: 195 hours
Maximum reimbursement for deliverable: $2300
D.Project Evaluation
Outcomes will be based on meeting the Projects Methods deliverables.
E.Reimbursement
Funds will be made available on a reimbursement basis only.
DHHS (Attachment B) (04/04) 1
Orange County Accomplishment Report Budget
Estimated
Number of
Task Hours Cost
Collect data and prepare the 2010 Accomplishment Report by.tune 15.2011. F195 hours $2,300
.............. .
_. ..................
ATTACHMENT,E .
FEDERAL CERTIFICATIONS
The undersigned states that:
1. He or she is the duly authorized representative of the Vendor named below;
2. He or she is authorized to make,and does hereby make,the following certifications on behalf of the Vendor,as set out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug-Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered
Transactions;and
e. The Certification Regarding Lobbying;
3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses at which the
contract work will be performed;
4. [Check the applicable statement]
❑ He or she has completed the attached Disclosure Of Lobbying Activities because the Vendor has made, or has an
agreement to make, a payment to a lobbying entity 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 a covered Federal action;
OR
�He or she has not completed the attached Disclosure Of Lobbying Activities because the Vendor has not made, and has
o agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or
employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of
Congress in connection with a covered Federal action.
5. The Vendor shall require its subco tractors,if any,to make the same certifications and disclosure.
Signature Title
Vendor Date
[This Certification Must Be Signed By The Same Individual Who Signed The Proposal Execution Page]
I. Certification Regarding Nondiscrimination
The Vendor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to:
(a)Title VI of the Civil Rights Act of 1964(P.L. 88-352)which prohibits discrimination on the basis of race, color or national origin;
(b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which prohibits
discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973;as amended(29 U.S.C. §794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which
prohibits discrimination on the basis of age;(e)the Drug Abuse Office and Treatment Act of 1972(P.L. 92-255), as amended,relating
to nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g)
Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale,rental or
financing of housing; (h)the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political
beliefs; and(i)the requirements of any other nondiscrimination statutes which may apply to this Agreement.
II. Certification Regarding Drug-Free Workplace Requirements
1. The Vendor certifies that it will provide a drug-free workplace by:
(a) Publishing a statement no employees that the unlawful manufacture, distribution, dispensing, possession or
use of a controlled substance is prohibited in the Vendor's workplace and specifying the actions that will be taken
against employees for violation of such prohibition;
(b) Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Vendor'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 be engaged in the performance of the agreement 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
agreement,the employee will:
(1) Abide by the terms of the statement;and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no
later than five days after such conviction;
(e) Notifying the Department within ten days after receiving notice under subparagraph (d)(2) from an employee or
otherwise receiving actual notice of such conviction;
(f) Taking one of the following actions, within 30 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;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;and
(g) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs(a),
(b),(c),(d),(e),and(fl•
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites; add
additional pages if necessary):
Street Address No. 1: 300 W J r-L4 t>» q"-Ge-f—
City, State,Zip Code: 14 , 4:;vr'pu_ a79-
Street Address No.2:
City, State,Zip Code:
3. Vendor will inform the Department of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination of
grants,or government-wide Federal suspension or debarment. 45 C.F.R. 82.510.
III. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227,Part C-Environmental Tobacco Smoke,also known as the Pro-Children Act of 1994(Act),requires that smoking
not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for
the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal
programs either directly or through State or local governments,by Federal grant, contract, loan, or loan guarantee. The law does not
apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of
facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of
a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an administrative compliance order on the responsible
entity.
The Vendor certifies that it will comply with the requirements of the Act.The Vendor further agrees that it will require the language
of this certification be included in any subawards that contain provisions for children's services and that all subgrantees shall certify
accordingly.
IV. Certification Regarding Debarment,Suspension,Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase"prospective lower tier participant"means the Vendor.]
1. By signing and submitting this document,the prospective lower tier participant is providing the certification set out below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this transaction
was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal Government, the department or agency with which this
transaction originate may pursue available remedies,including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is submitted '
if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, "ineligible," lower tier covered transaction," "participant,"
"person," "primary 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, 45 CFR Part 76.
You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be
entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended,
determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the
department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction,"
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 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 Nonprocurement List.
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 in 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 department or agency
with which this transaction originated may pursue available remedies, including suspension,and/or debarment.
Certification
a. The prospective lower tier participant certifies, by submission of this document, 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.
b. 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.
V. Certification Regarding Lobbying
The Vendor 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 any Federal,state,or local government agency,a Member of
Congress, a Member of the General Assembly, an officer or employee of Congress, an officer or employee of the General
Assembly, an employee of a Member of Congress,or an employee of a Member of the General Assembly in connection with
the awarding of any Federal contract,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 Federal, state or local government agency, a Member of Congress, a Member of
the General Assembly, an officer or employee of Congress, an officer or employee of the General Assembly,an employee of
a Member of Congress or an employee of a Member of the General Assembly in connection with this Federally funded
contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL,
"Disclosure of Lobbying Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for subawards at all
tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who receive federal
funds of$100,000.00 or more and that all subrecipients shall certify and disclose accordingly.
4. 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$10,000.00 and not more than$100,000.00 for each such failure.
VI. Disclosure Of Lobbying Activities
Instructions
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 Federal or state or local agency, a Member of Congress, a Member of the General assembly, an officer or
employee of Congress,an officer or employee of the General Assembly„ an employee of a Member of Congress or an employee of a
Member of the General Assembly 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 sub-award 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 known.
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 boxes. 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 boxes. 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 number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for
reviewing instructions, 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
Disclosure Of Lobbying Activities
(Approved by OMB 0344-0046)
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
0 c. cooperative agreement ❑ c. Post-Award
❑ d. loan For Material Change Only:
0 e. loan guarantee
0 f. loan insurance Year Quarter
Date Of Last Report:
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee, Enter Name
and Address of Prime:
0 Prime
❑ Subawardee 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 Services(including address if
(if individual,last name,first name, MO: different from No. 10a.) (last name, first name, MO:
(attach Continuation Sheet(s)SF-LLL-A,if necessary) (attach Continuation Sheet(s)SF-LLL-A,if necessary)
11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply):
$ ❑ actual ❑ planned ❑ a. retainer
❑ b. one-time fee
12. Form of Payment(check all that apply): ❑ c. commission
0 d. contingent fee
❑ a. cash 0 e. deferred
0 b. In-kind;specify: Nature ❑ f. other; specify:
Value
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)SF-LLL-A,if necessary):
15. Continuation Sheet(s)SF-LLL-A attached: ❑ Yes ❑ No
16. Information requested through this form is authorized by Signature:
title 31 U. S.C.section 1352. This disclosure of lobbying
activities is a material representation.of fact upon which Print Name:
reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required Title:
pursuant to 31 U. S. C. 1352. This information will be
reported to the Congress semi-annually and will be Telephone No: Date:
available for public 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.
0�' Authorized for Local Reproduction
Standard Form-LLL