HomeMy WebLinkAboutAgenda - 04-01-1997 - 8g t
1
ORANGE COUNTY
BOARD OF COMMISSIONERS
Action Agenda
Item No. $.q
ACTION AGENDA ITEM ABSTRACT
Meeting Date: April 1, 1997
SUBJECT: Authorization of the RSVP Renewal Application and Agreement
DEPARTMENT: PUBLIC HEARING: YES: NO:_X_
Department on Aging
ATTACHMENT(S): INFORMATION CONTACT:
Jerry M. Passmore, Director, ext. 2000
(1) RSVP Resolution for Submission(pg. 2-3) TELEPHONE NUMBER:
Hillsborough- 732-8181
(2) Final Application(pg. 4-13) Chapel Hill - 968-2054
Mebane - 227-2031
(3) Pro Forma Grant Award Notice (pg. 14-19) Durham - 688-7331
PURPOSE:
To consider approving an application for a 3 year renewal of federal grant funding for RSVP. To request
approval of the RSVP (Retired and Senior Volunteer Program) final application and to enter into an
agreement with Corporation for National Service for the period July 1, 1997 through June 30, 2000 in the
amount of$112,530($37,510 per year) in federal funds. (See tabulation PG. 7.)
BACKGROUND:
This is a 3 year Application for Federal Assistance covering volunteer services provided by 610 retirees
serving approximately 70,000 hours through non-profit organizations in Orange County each year. The
federal sponsor has honored.long running, high quality Corporation for National Service programs by al-
lowing them to submit a 3 year federal funding application (PG. 5). This has been done in order to save
time for staff and sponsor by deleting much of the paperwork required in the annual application. RSVP
will continue to work under a one year budget plan (PG. 6-7.) It will be necessary for RSVP to submit
annualized budget revisions to the federal sponsor to show changes in either the federal or local funding
levels. Local funding requirements continue as before based on the annual Orange County budgeting
process. The RSVP objectives will include recruiting, placing, and recognizing these volunteers. RSVP
will also provide the non-profit agencies support and training in the area of volunteer management. RSVP
has developed a 3 yr. work plan. RSVP will also strive to identify community needs and provide volunteer
programming and management targeting these needs.
Impact: Minimal increases in matching funds for continuation of the program grant next year would be for
RSVP staff merits and cost of living increases.
RECOMMENDATION(S):
Manager recommends approval of RSVP resolution, 3 year application, and agreement and authorize Chair
to sign application and Notice of Grant Award when received with the understanding that the 3 yr. applica-
tion does not affect the Orange County annual budgeting process and can be terminated at anytime based
on Corporation for National Service handbook guidelines providing for advance notice in order to find
another local sponsor.
2
A RESOLUTION AUTHORIZING SUBMISSION OF A GRANT APPLICATION
FOR THE RETIRED SENIOR VOLUNTEER PROGRAM (RSVP)
BE IT RESOLVED by the Commissioners of Orange County that the Commissioners
authorize the County Manager to submit an application to Corporation for National
Service for a $112,530 three year grant ($37,510/year) for continuation of the Retired
Senior Volunteer Program for thirty-six months and to certify to the federal government
the willingness of the County to assure a minimum of 30% in cash, goods, and services as
the non-federal share in support of the program. Funding will continue to be reviewed
and approved on an annual basis as part of the Orange-County Budget Process and the
RSVP will operate under a one year budget. Budget revisions will be submitted to the
Federal Sponsor at the end of the first and second years.
It is understood that Orange County is not locked into a commitment for three years if it
is decided by Orange County officials to discontinue support of the Orange County
RSVP. The program can be terminated at anytime based on the Corporation for National
Service Handbook guidelines providing the required advance notice.
This is the First day of April, 1997.
" 3
CERTIFICATE OF RECORDING OFFICER
The undersigned duly qualified and Clerk of the Orange County Board of
Commissioners does hereby certify:
That the attached resolution is a true and correct copy of the resolution to author-
ize the County Manager to submit an application to Corporation for National Service for
a $112,530 three year grant ($37,510 per annual budget period) for continuation of the
Retired Senior Volunteer Program for thirty-six months and to assure minimum annual
support of this program of 30% in cash, goods, and services, and further, that such reso-
lution has been fully recorded in the journal of proceedings and recorded in my office.
IN WITNESS WHEREOF, I have hereunto set my hand this day of April 1, 1997
ORANGE COUNTY BOARD OF COMMISSIONERS
BY:
Beverly A. Blythe, Clerk
4
ORANGE COUNTY
RETIRED & SENIOR VOLUNTEER PROGRAM
1997 - 2000
CORPORATION FOR NATIONAL SERVICE
GRANT APPLICATION
5
APPLICATION FOR Part I SF-424 OMB Approvd No.0348.0047
4 2.DATE SUBMITTED Applicant Identifier
FEDERAL ASSISTANCE 03-12-97 none
1.TYPE OF SUBMISSION: 3.DATE nECFJVED BY STATE' Stale Application Identifier
Appllceflon j Preeppllcaflon
❑Construction ❑ Construction
❑Non-Construction ❑ Non•Conslrucibn 4.DATE RECEIVED BY FEDERAL AGENCY Federal Identifier
440S136/17
S.APPLICANT INFORMATION
Legal Name: Organizational Unit
Orange County County Gayprnmpnt
Address(give cJty,county,stale,and zip code): Name and telephone number of the person to be contacted on matters
Orange County involving this application(give area code):
P. O. Box 8181
Hillsborough, Orange County, NC 27278 Katherine L. Porter (Kathy) , RSVP Director
D (919) 968-2054
6. EMPLOYER IDENTIFICATION NUMBER(EIN) 7. TYPE OF APPLICANT:(enter appropriate letter in box) ®B
A. Slate H. Independent School District
5 TE — 6 0 0 0 3 2 B. County I. State Controlled Institution of Higher Learning
_ C. Municipal J. Private University
6. TYPE OF APPLICATION: D. Township K. Indian Tribe
❑ New K7 Continuation ❑ Revision E. interstate L. Individual
F. Inlermunicipal M. Profit Organization
II Revision,enter appropriate letter(s)in box(es): 0 ❑ G. Special District N. Other(Specify):
A. Increase Award B. Decrease Award C. Increase Duration
D. Decrease Duration Other(specify): 9. NAME OF FEDERAL AGENCY:
Corporation for National Service
National Senior Service Corp
10. CATALOG OF FEDERAL DOMESTIC 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
ASSISTANCE NUMBER: 2 0 0
11E: Retired & Senior Volunteer Program
12. AREAS AFFECTED BY PROJECT(Cities,Counties,stafos,otc):
Hillsborough, Chapel Hill, Carrboro,
Orange County, North Carolina, Chatham
13. PRO S JECT: 14. CONGRESSIONAL DISTRICTS OF: —'
Start Date Ending Date a. Applicant b. Project
07/01/97 06/30/2000 Fourth Fourth
15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?
a. Federal $ .00 a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE
112,530 STATE EXECUTIVE ORDER 12372P nOCESS FOR REVIEW ON:
b. Applicant $ .00 03/12/97
1017 945 DATE
c. Slate $ .00
b. NO. ❑ PROGRAM IS NOT COVERED BY E.O. 12372
d. Local $ .00
39,531 ❑ OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
e. Other S .00
I. Program Income $ 00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
Cl Yes If"Yes,"attach an explanation. No
g. TOTAL $ 253,506 D0
18, TO THE BEST OF MY KNOWLEDGE ANO BELIEF,ALL DATA IN THIS APPLICAnownEAPPLICATiON ARE TRUE AND CORRECT,THE DOCUMENT HAS BEEN DULY
AUTHORIZED by THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE Is AWARDED
a. Typed Name of Authorized Representative b. title
William L. Crowther (Bill) Chair-.Orange Co. Commissioners
d. Signature of Authorized Representative e. Dale Signed
Prevloan EJIllont Not U,nINe Aulhorlrod Irx Lrx:nl nnprrx/ut6on I'�1�;C � Sla vl.vd I'mm•1?4(nov.A.no�r,.____:r,-•.,.nun r•;,,.,,i.,,n.uq
PAGE l
PART I I - BUDGET 6 ,
(1) VOLUNTEER SUPPORT EXPENSES
a. GRANTEE PERSONNEL (1) (2) (3) (11) (5) (6)
EXPENSES Annual %Time Total Federal Funds Mon-Federal Excess
Position Title Salary SpetIt otk Cost Requested Resources Resources
Project
$
% $ $ $ $
RSVP Project Director 30,764 100 30,764 14,242 7,189 9,333
Asst. RSVP Director 23,244 100 23,244 11,654 6,133 5,457
RSVP Admistrative Asst. 4,200 100 4,200 -0- -0- 4,200
TOTAL PERSONNEL EXPENSES IS 58,208 100 % $58,208 $ 25,896 $ 13,322 $18,990
b. FRINGE BENEFITS M j
c. (1)GRANTEE STAFF LOCAL TRAVEL 150 150
c. (2) GRANTEE STAFF LONG DISTANCE TRAVEL 600 600
d. EQUIPMENT 1 1
e. SUPPLIES 299 18 281
f. CONTRACTUAL SERVICE
g. OTHER: Prof. Dues 100 100
Communications Postage 800 200 600
Printing & Duplication 400 200 200
Space
b. INDIRECT COSTS
• ' 'It SUIT SUITURT EXPENSES $74,488 $ 30,249 $ 15,878 $ 28,361
(2) VOLUNTEER EXPENSES
a. PERSONNEL EXPENSES
Stipends
�L�F
::kk•:•ii}iii iJ:•::i'::::•:•i ki:`J::?: i:::J:i:LJ:^::�kk:�{iti4i:�iiii:'vii iiii:Si:i•:�
:J::i:y::••r;J••J'•:;x•Ji:;•u;<.Jr.;JJ:,::k't::{t<::::J:;:::{;:i:;•.:i':>i;ii•::ii;r;{;::Y;:i::i:i::i:i:t:;:?:::
...............
;t..:.
:.::.J•.JJ....t:.JJ}.:;:.:,,,..:::..:........:.JJ':.JJ.::.:�:J:J:::k:a::.;i'J:;•J;::J::.»J<::J»:.;:>:.<:'J:is>.:i•:;.J:.;:t;:::t.:t.;:::::.J:::.;;;
...................... . .......
........:.:.......... ... ....
b. FRINGE BENEFITS
Meals 40 40
...�,... ?.J:.,:......r:::::.:.:}::.....,:...;}J:aJ;.f'.:....r..::::::....::..::JJ::}:;J:.:::.:::.::t.>:.J:J..J:.:.JJ';>:.:.;:.;:.:..;:.;;•.:;:.:;:::.:JJ:.:JJ::::.�:.::
Uniforms _
Insurance 1,540 979 561
Recognition 4,800 3,000 1,800
Otber:
c. TRAVEL 3,534 3,182 352
:..�
t•;.•:.}•..:••.::. .t:a:.}:a}:.JJ:::.J:::.:;:.JJJJJ:.:.JJ>J:�JJ:.JJJ::.J;:.J>:.J;;:.:
.vv.
., .. .. .............. ..... .. .. >::.i{t<:::': :•;:;:•: :2•':^f�.arti J•¢+:
':•:t^:4i'•::1.�`:L:aii}:?•J:;{.::. aJ}:�J}f:•J';a .
a:aJ:• S::i:k•
?p...•... .•... ..:...r:�':w. :?•:aJ.<?::<^S'J}}JJJ:?;a:t?•};4i:!oJ:�ii:i:t?:>.•
h.., ... .. }.:.?:::::::•:::::::. ::..::�.. ,................... ::::. :.::::..:.:.t%:::r:r:'{. J ;:i:t:u^ii'<::r:iJ::i
.....................................................
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•iiit:
.............................
...........:::::::::::::.
i .: ::. {y t4'•}'.;•.;.:.•::.;•, } ....::.i::'i'::<:i:s'i:•,'ri:::::::::'i::i::::Jr?`6ii:
v:['t.::>... � :� FYI•..
g OTHER: Orientation to Corp. (NSSC & 100 100
RSVP) Print Volunteer Handbook
h. TOTAL VOLUNTEER EXPENSES ,$10,014 7,261 -0- , 2,753
1. TOTAL COSTS $84,_502 $ 37,510 $ 15,878 $ 31,114
(3) PERCENTAGES 100% 70% 30$
Corporation Form 424-AA U94 Modified
rP t' ) Prescribed by OMB Circular A-102
PAGE 6
7
RSVP FEDERAL BUDGET
1996-97 1997-98
BUDGET PROPOSED
STAFF SALARIES $57, 924 $58,208
STAFF FRINGE BENEFITS 13 , 781 13, 930
STAFF TRAVEL 750 750
EQUIPMENT 3 , 277*
SUPPLIES 300 300
OFFICE SPACE (IN-KIND)
POSTAGE AND PHONE 800 800
PRINTING & DUPLICATING 500 500
PERIODICALS, DUES, ORIENTATION 100 100
VOLUNTEER MEALS 40 40
VOLUNTEER TRANSPORTATION 3 , 534 3, 534
VOLUNTEER RECOGNITION 4 , 800 4, 800
VOLUNTEER INSURANCE 1, 5.40 1, 540
$87, 346 $ 84, 504
RSVP REVENUE SOURCES
1996-97 1997-98
BUDGET PROPOSED
FEDERAL FUNDING FROM ACTION $39, 854* $37, 510
NON-FEDERAL FUNDING 47, 492 46, 994
Cash Revenues
Orange County 34 , 315 33, 817
Town of Chapel Hill 12, 277 12,277
Town of Carrboro 900 900
Total Cash Revenues $47, 492 $46, 994
TOTAL REVENUE: (100%) $87, 346 (100%) $84, 504**
*Please note that the 1996-97 Federal funding level depicts
($39, 854) an additional one time award of $3 , 277 . RSVP staff
requested end-of-the year wish list funds from the Federal
sponsor. This amount was awarded to purchase a computer and
printer.
FN:COBUDGET\BUD9798 .DOC
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11
Programming for Impact: Getting Things Done
5 - Element Planning Statement
RSVP/Community and Economic Development/Tax Consulting/Counseling( 729
5 Key Elements Element Descriptions
Community Need Based on statistics from the 1990 Census, approximately 10,480 Orange County households have
incomes between $0 and $17,500. Some residents with tow-middle income, including the dis-
abled and/or elderly,and non-English speaking,may not file and receive the tax refunds due them
because they are unable to pay for assistance or because they are physically unable to leave their
homes. Many will not file because they do not understand the forms. In addition,IRS offices are
down-sizing and many taxpayers will be referred elsewhere for assstance.
Service Activity Trained RSVP volunteers will serve the target population as VITA (Volunteer Income
Tax Assistance) tax preparers. VITA does not have specific income guidelines. Each
situation is evaluated by the volunteer to determine if assistance should be provided or
if the taxpayer should be referred to a paid preparer. Volunteers are trained to file fed-
eral/state returns,many special schedules/forms and electronic filing. The RSVP-VITA
program will be offered county-wide at 5 sites during the tax season(2 senior centers-2
days/wk, 1 health center-1 day/wk, 1 hospital-1 day/week, 1 handicap employment pro-
gram 3 days/season). February 1-April 15: 5 sites will be open approximately 25 hours
weekly. Sites operate on different days (Monday - Saturday) and time schedules vary
in order to accommodate the taxpayer. The service will be offered the rest of the year
on an as-needed basis. Some sites will provide walk-in service and others will provide
service by appointment only. Volunteers will ask taxpayers to complete a short survey
depicting their level of satisfaction with the service and taxpayers will be asked to make
suggestions for improvement. Volunteers will record the type of service provided, ages
of clients, number and amount of refunds, and number of those not receiving refunds.
All services are provided free of charge.
Input 30 RSVP volunteers will attend a-week long 40 hour training session on preparing state
and federal tax returns and a 2 day workshop on electronic filing. Volunteers will serve
approximately 4 hours per week for 10 weeks totally an estimate of 1,200 hours for the
tax season. The IRS and State Division of Taxation will provide the training at an es-
timated value of $100/trainee totaling $3,000 (in-kind). Volunteer CIMA insurance
coverage is provided at approximately $5/volunteer/year totaling $150; annual recogni-
tion cost is $10/volunteer totaling $300; donated site space estimated prorated value is
$4,000_calculated at $13 X 1500sq ft; staff support, copy machine use, computers, pa-
per, and supplies are donated or provided by RSVP (estimated value $3,200). RSVP
staff will coordinate the training, develop sites, set volunteer schedules, publicize the
service weekly through 23 media contacts and distribute fliers, accumulate data and
keep records,monitor sites, transmit and process returns submitted for electronic filing,
and provide a special recognition/training event after the tax season. RSVP staff will
work with local county agencies (Meals-on-Wheels, Social Services, Health Dept.,
Housing, Aging, Nutrition Sites, etc.) working with low to middle income residents to
get the VITA publicity to their clients. RSVP staff and key volunteers will work to
get loaned or donated computers/printers from local computer companies and the local
sponsor. Some computers and printers will be purchased based on funds available.
Accomplishments It is estimated that 700 of the target population will have received volunteer tax assis-
(Antieipated) tance resulting in accurate on-time filings and refunds. The actual accuracy level will
be determined by computerized results provided by the State and IRS assessing the ac-
curacy of the trained VITA Volunteers.
Impact Calculated at the average commercial filing charge($75.00),the volunteers will pro-
(Anticipated) vide over$52,500 annually in free services and savings to the target population. This
will result in an additional infusion of approxim$ 70,000 into the community if each of
the 700 taxpayers receives an average refund of$100.
PAGE 13-U
OMB Approval No.0348-0040 12
ASSURANCES - 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. and the in--' S. Will comply with the provisions of the[latch Act(5 U.S.C.§§1501-1508
stitutiatal,managerial and financial capability(including funds suffi- and 7324-7328)which limit the political activities of employees whose
cient to pay the non-Federal share of project costs) to ensure proper principal employment activities are funded in whole or in part with
planning,management and completion of the project described in this Federal funds.
application. 9. Will comply,as applicable.with the provisions of the Davis-Bacon Act
2. Will give the awarding agency,the Comptroller General of the United (40 U.S.C.if 276s and 276a-7),the Copeland Act(40 U.S.C.§276c and
States,and if appropriate,the State,through any authorized representa- 18 U.S.C.§§874),and the Centract Work Hours and Safety Standards Act
tive,access to and the right to examine all records,books,papers,or (40 U.S.C. §§327-333),regarding labor standards for federally assisted
documents related to the award;and will establish a proper accounting construction subegroernents.
system in accordance with generally accepted accounting standards or 10. Will comply,if applicable,with flood insurance purchase requirements of
agency directives. Section 102(a)of the Flood Disaster Protection Act of 1973(P.L.93-234)
3. Will establish safeguards to prohibit employees from using their posi- which requires recipients in a spocial flood hazard area to participate in the
tions for a purpose that constitutes orprescrits the appcaranceof personal program and to purchau flood insurance if the total cost of insurable
or organizational conflict of interest,or personal gain. construction and acquisition is S 10,000 or mote.
4. Will initiate and complete the work within the applicable time frame it. Will comply with environmental standards which may be prescribed
after receipt of approval of the awarding agency. pursuant to the following:(a)institution of environmental quality control
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 measures under the Notional 1?nvironmental Policy Act of 1969(PL.91-
U.S.C.Of 4728-4763)relating to prescribed standards for merit systems 190, and Executive Order (EO) 11514; (b) notification of violating
for programs funded under one of the nineteen statutes or regulations facilities pursuant to EO 11738;(c)protection of wetlands pursuant to EO
specified in Appendix A of OPM's Standards for a Merit System of I IS90 ;(d)evaluation of flood hazards in floodplains in accordance with
Personnel Administration(5 C.F.R.900,Subpart F). EO 11988;(e)assurance of project consistency with the approved State
6. Will comply with all Federal statutes relating to nondiscrimination. management program developed under the Coastal Zone Management
These include but are not limited to:(a)Title V1 of the Civil Rights Act Act of 1972(16 U.S.C.§§ 1451 ct seq.);(Q conformity of Federal actions
of 1964(P.L.88-352)which prohibits discrimination on the basis of to State (Clean Air)implementation Plans under Section 176(c)of the
race,color or national origin;(b)Tide LX of the Education Amendments Clean Air Act of 1955, as amended (42 U.S.C. § 7401 et seq.); (g)
of 1972,as amended(20 U.S.C.§§ 1681-1683,and 1685-1686).which protection of underground sources of drinking water under the Safe
prohibits discrimination on the basis of sex; (c) Section 504 of the Drinking Water Act of 1974,as amended(P.L.93-523);and(h)protection
Rehabilitation Act of 1973, as amended (29 U.S.C. § 794), which of endangered species under the Endangered Species Act of 1973,as
prohibits discrimination on the basis of handicaps;(d)the Age Discrimi- �unended(P.L.93-205).
nation Act of 1975, as amended (42 U.S.C. §§ 5101-6107), which 12 Will comply with the Wild and Scenic Rivers Act of 1968(16 U.S.C.if
prohibits discrimination on the basis of age;(e)the Drug Abuse Office 1271 et seq.)related to protecting components or potential components of
and Treatment Act of 1972 (P.L. 92-255), as amended, relating to the national wild and scenic rivers system.
nondiscrimination on the basis of drug abuse; (f) the Comprehensive 13. Will assist the awarding agency in assuring compliance with Section 106
Alcohol Abuse and Alcoholism Prevention.Treatment and Rehabilita- of the National historic['reservation Act of 1966,as amended(16 U.S.C.
don Act of 1970(P.L.91-616),as amended.relating to nondiscrimina- 470).EO 11593(identification and protection of historic properties),and
tion on the bads of alcohol abuse or alcoholism;(g)§§523 and 527 of the Archaeological and 1-lisuotic_Pteservation Act of 1974 (16 U.S.C.
the Public Health Service Act of 1912(42 U.S.C.290 dd-3 and 290 cc- 469a-I et seq.).
3),as amended,relating to confidentiality of alcohol and drug abuse 14. Will cumply with P.L.93-348 regarding the protection of human subjects
patient records;(h)Title V111 of the Civil Rights Act of 1968(42 U.S.C. involved in research.development,and related activities supported bythis
13601 et seq.),as amended,relating to nondiscrimination in the sale, award of assistance.
rental or financing of housing;(i)any other nondiscrimination provi- 15. Will comply with the Laboratory Animal Welfare Act of 1966(P.L 89-
sions in the specific statute(s) under which application for Federal 541,as amended,7 U.S.C.2131 et seq.)pertaining to the care,handling,
assistance is being made;and V)the requirements of any other nondis- and treatment of warm blooded animals held for research.leaching,or
csimiradon statute(s)which may apply to the application. other activities supported by this award of assistance.
7. Will comply,or has already complied,with the requrementsof Titles If 16. Will comply with the 1-cad-Rased Paint Poisoning Prevention Act (42
and III of the Uniform Relocation Assistance and Real Property Acqui- U.S.C. §§ 4801 et seq.) which prohibits the use of lead-based paint in
sition Policies Act of 1970(P.L 91-646) which provide for fair and zonswction or rehabilitation of residential structures.
equitable treatment of persons displaced or whose property is acquired 17. Will cause to be performed the required financial and compliance audits
as a result of Federal or federally assisted programs.These requirements in accordance with the Single Audit Act of 1984.
apply to all interests in real property acquired for project purposes 18. Will comply with all appficable requirements of all other Federal laws,
regardless of Federal participation in purchases. executive orders,regulations and policies governing this program.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAI. TITLE
APPLICANT ORGANIZATION DATE SUBMITTED
PAGE 14
Page 9
Authorized for I,oad Reproduction Standard Torun 4248 (4-88)
fresaibed by OMB Circular A-102
13
a
CERTIFICATIONS REGARDING(A) DEBARNiE.NT,SUSI'ENSiON AND OTIIER RESi'ONSIBILiTY MATTERS;
(B)DRUG-FREE WORKPLACE,RF,t2UIREMENTS;AND(C) LOBBYING
Applicants should refer to the regulations cited below to determine which ccitifica!ion(s) apply to their grant,and review the instnnetions included in the
regulations. Signing this form complies with certification requirements under "Government-wide Debarment and Suspension (Nonprocurement)" and
"Government-wide Requirements forDrug-Free Workplace(Grants)"(under-15 CFK Part 1229),and"New Restrictions on Lobbying"(under 45 CFR Part 1230).
The certification(s)shall be treated as material representation of fact upon which reliance will be placed when the Corporation determines to award the covered
transaction,grant,or cooperative agreement.
A. DEBARMENT,SUSPENSION,AND OTHER RESPONSIBiL- criminal drug statute which occurred in(he workplace,no later than
ITY MATTERS five calendar days after such conviction;
As required by Executive Order 12549, Debarment and Suspension, and (c)Notify the cognizant Corporation Grants Officer within ten calendar
implemented at 45 CFR Part 1229, for prospective participants in primacy daysaRer receiving notice of such conviction under subparagraph(d)(2)
covered transactions,as defined at 45 Ci-R Part 1229,Sections 1229.105 and front the employee,or otherwise receiving actual notice. The notice
1229.110— shall include the title of the employee's position and the identification
1. The applicant certifies that it and its principals: awnber(s)or each affected gran(;
(a) Are not presently debarred, suspended, proposed for debarment, (f)'hake one of the following actions,within 30 calendar days of receiving
declared ineligible,or voluntarily excluded from covered Uano-ac- notice under subpk-uagraph 46,with respect to any employee who is so
lions by any Federal department or agency; convicted—
(b) Have no(, witldn a three-year period preceding this application, (I)Take appropriate personnel action against such an employee up to
been convicted of or had acivil judgment rendered against them for and including termination consistent with the requirements of the
commission of fraud or a criminal offense in connection with RchaHlitation Act of 1973,as amended;or
obtaining,attempting to obtain,or performing a public (Fede:al, (2)Require such employee to participate satisfactorily in a drug abuse
State or local)transaction or contract under a public transaction; assistance or rehabilitation program approved for such purposes by
violation of Federal or State antitrust statutes or commission of a Fcdcral,Slate or local licalth,law enforcement,or other appropri-
embezzlement,theil,forgery,bribery,falsi ficatibn or destruction of ate agency;
records,making false statements,or receiving stolen propery-, (g)Make a good faith effort to continue to maintain a drug-free workplace
(c) Are not presently indicted for or otherwise criminally or civilly through implementation of paragraphs I(a)through 1(p.
charged by a Federal,State or local governnnententity wit heomrmis_ 2• 'Ilse grantee shall insert in the space provided below the site(s) for the
sion of any of the offenses enumerated in paragraph I(b)of this performance of work done in connection with the specific grant:
certification; Place of Performance(Street address,city,county,state,zip code):
(d) Have not,within a three-year period preceding this application,had
one or more public transactions(Federal.State or local)terminated
for cause or default;and _-
2. Where the applicant is unable to certify to any of the statements in this U. Check here if there arc grantee workplaces that are not identified above.
certification,he or she shall attach an explanation to this application. C. LOBBYING
B.DRUG-FREEWORKPLACE(GRANTEES 01'1lER TIIAN As required by Section 1352,Title 31 of the U.S.'Code,and implemented
INDIVIDUALS) at 45 CPR['art 1230,for organizations entering into a grant or cooperative
As required by the Drug-Free Workplace Act of 1988,and implemented at 45 ng-cement over 31(0,000,as dcfrned at 45 C17R Part 1230,Sections
CM Part 1229, Subpart F, for grantees, as defmcd at 45 CFR Part 1229, 1230.1105 and 1230.1 10,ifie applicant certifies that:
Sections 1229.605 and 1229.610— L No Federal appropriated funds have been paid or will be paid,by or on
1.The applicant certifies that it will or will continue to provide a drug-free behalf of the undersigned,to any person for influencing or attempting to
workplace,and will: inllucnce an officer or employee of any agency,a Member of Congress,
(a)Publish astatement notifying employees that the unlawful manufacture, an officer or employee of Congress,or an employee of a Member of
distribution,dispensing,possession or use of a controlled substance is Congress in connection with the awarding of any Federal contract,the
prohibited in the grantee's workplace and specifying the actions that will making of any Federal grant,the making of any Federal loan,the
be taken against employees for violation of such prohibition; criering into of any cooperative agreement,or the extension,continua-
(b)Establish an on-going drug-free awareness program to inform employ- lion,renewal,amendment,or modification of any Federal contract,
ecs about— grant,loan,or cooperative agreement.
(1)The dangers of drug abuse in the workplace; 2. if any funds other than Federal appropriated funds have been paid or
(2)The grantee's policy of maintaining a drug-free workplace; will be paid to airy person for influencing or attempting to influence an
(3)Any available drug counseling,rehabilitation,and employee as-as- of ricer or employee of any agency,a Member of Congress,an officer or
Lance programs;and employee of Congress,or art employee of a Member of Congress in
(4)The penalties that may be imposed upon employees for drug abuse connection with this Federal contract,grant,loan,or cooperative
violations occurring in the workplace. agreement,the undersigned shall complete and submit Standard Form-
(c)Make it a requirement that each employee to be engaged in the perfor- LLL,"Disclosure Fonn to Rcport Lobbying,"in accordance with its
mance of the grant be given a copy of the statement required by instnrc(ions.
paragraph I(n); 3. The undersigned shall require(hat the language of this certification be
(d)Notify the employee inthestalementrequircdbysubparagraph 1(a)thdt, included in the award documents for all subcontracts at all tiers
as a condition of employment under the grant,the employee will— (including subcontracts,subgrants,and contracts under grants,loans,
(1)Abide by the temis of the statement;and at,,:cooperative agreements)and that all subrecipients shall certify and
(2)Notify the employer in writing of any conviction for a violation of a Jisclose accordingly.
As the duly a,ahorized representative of the applicant,I hereby certify that rite app scant will comply with the above certilication(s). A copy o the governing
body's authorization for me to sign this certification as official representative is oil file in(he applicant's office.)
Applicant Organization Printed Nante and'hitle of Authorized Representative
Signature of Authorized Certifying Official Date
Corporation ronli 4240-C (4/94)
Page 11.0 PAGE 15
14
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