HomeMy WebLinkAbout2014-501 Aging - TJCOG Home and Community Care Block Grant for Older Adults abli/-53,1
DOA-735
(revised 7/14: #23  added)
July 1, 2014 Through June 30, 2015
Home and Community Care Block Grant for Older Adults
Agreement for the Provision of County-Based Aging Services
This Agreement, entered into as of this the first day of July, 2014,by and between the County of
Orange (hereinafter referred to as the "County") and the Triangle J Council of Governments Area
Agency on Aging, (hereinafter referred to as the "Area Agency").
Witnesseth That:
WHEREAS, the Area Agency and the County agree to the terms and conditions for provision of aging
services in connection with activities financed in part by Older Americans Act grant funds,provided to
the Area Agency from the United States Department of Health and Human Services through the North
Carolina Division of Aging and Adult Services (DAAS)and state appropriations made available to the
Area Agency through the North Carolina Division of Aging and Adult Services, as set forth in a)this
document, b)the County Funding Plan, as reviewed by the Area Agency and the Division of Aging and
Adult Services, c)the Division of Aging and Adult Services Home and Community Care Block Grant
Procedures Manual for Community Service Providers, d) the Division of Aging and Adult Services
Service Standards Manual, Volumes I through IV, and, e) the Division of Aging and Adult Services
Community Service Providers Monitoring Guidelines.
NOW THEREFORE, in consideration of these premises, and mutual covenants and agreements
hereinafter contained, the parties hereto agree as follows:
1. As provided in the Area Plan, community service providers specified by the County to
encourage maximum collocation and coordination of services for older persons are as follows:
Central Orange Senior Center Robert and Pearl Seymour Center
1.(a) The Community Service Provider(s), shall be those specified in the County Funding Plan on the
Provider Services Summary format(s) (DOA-732) for the period ending June 30 for the year
stated above.
2. Availability of Funds. The terms set forth in this Agreement for payment are contingent upon
the receipt of Home and Community Care Block Grant funding by the Area Agency.
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3. Grant Administration. The grant administrator for the Area Agency shall be Joan M. Pellettier,
Director, Area Agency on Aging. The grant administrator for the County shall be Cheryl
Young,Assistant County Manager.
It is understood and agreed that the grant administrator for the County shall represent the
County in the performance of this Agreement. The County shall notify the Area Agency in
writing if the administrator changes during the grant period. Specific responsibilities of the
grant administrator for the County are provided in paragraph seven(7) of this Agreement.
4. Services authorized through the County Funding Plan, as specified on the Provider Services
Summary format(s) (DOA-732) are to commence no later than July 1 of the state fiscal year and
shall be undertaken and pursued in such sequence as to assure their expeditious completion.
All services required hereunder shall be completed on or before the end of the Agreement
period, June 30 of the state fiscal year.
5. Assignability and Contracting. The County shall not assign all or any portion of its interest in
this Agreement. Any purchase of services with Home and Community Care Block Grant for
Older Adults funding shall be carried out in accordance with the procurement and contracting
policy of the community services provider or,where applicable,the Area Agency, which does
not conflict with procurement and contracting requirements contained in 45 CFR 92.36.
Federal funds shall not be awarded to any subreceipients who have been suspended or debarred
by the Federal government. In addition, Federal funds may not be used to purchase goods or
services costing over$100,000 from a vendor that has been suspended or debarred from Federal
grant programs.
6. Compensation and Payments to the County. The County shall be compensated for the work and
services actually performed under this Agreement by payments to be made monthly by the Area
Agency. Total reimbursement to the community service providers under this Agreement may
not exceed the grand total of Block Grant funding, as specified on the Provider Services
Summary format(DOA-732).
(a) Interim Payments to the County
Upon receipt of a written request from the County, the Division of Aging and Adult
Services, through the Area Agency, will provide the County Finance Officer with an
interim payment equivalent to seventy percent(70%) of one-twelfth(1/12) of the
County's Home and Community Care Block Grant allocation by the 22nd of each
month.
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(b) Reimbursement of Service Costs
Reimbursement of service costs are carried out as provided in Section 3 of the N.C.
Division of Aging and Adult Services Home and Community Care Block Grant
Procedures Manual for Community Service Providers,revised February 17, 1997.
c) Role of the County Finance Director
The County Finance Director shall be responsible for disbursing Home and Community
Care Block Grant Funding to Community Service Providers in accordance with
procedures specified in the N.C. Division of Aging and Adult Services Home and
Community Care Block Grant Manual for Community Service Providers,revised
February 17, 1997.
(d) Payment of Administration on Aging Nutrition Services Incentive Program (NSIP)
Subsidy
NSIP subsidy for congregate and home delivered meals will be disbursed by the
Division of Aging through the Area Agency to the County on a monthly basis, subject to
the availability of funds as specified in Section 3 of the N.C. Division of Aging and
Adult Services Home and Community Care Block Grant Procedures Manual for
Community Services Providers,revised February 17, 1997.
If through the US Department of Agriculture Area Agency on Aging Elections Project,
the County elects to receive a portion of its USDA entitlement in the form of surplus
commodity foods in lieu of cash,the Area Agency will notify the County in writing of
its community valuation upon notification from the Division of Aging and Adult
Services. The delivery of commodity and bonus foods is subject to availability. The
County will not receive cash entitlement in lieu of commodities that are unavailable or
undelivered during the Agreement period.
7. Reallocation of Funds and Budget Revisions. Any reallocation of Block Grant funding between
counties shall be voluntary on the part of the County and shall be effective only for the period
of the Agreement. The reallocation of Block Grant funds between counties will not affect the
allocation of future funding to the County. If during the performance period of the Agreement,
the Area Agency determines that a portion of the Block Grant will not be expended,the grant
administrator for the County shall be notified in writing by the Area Agency and given the
opportunity to make funds available for reallocation to other counties in the Planning and
Service Area or elsewhere in the state.
The County may authorize community service providers to implement budget revisions which
do not cause the County to fall below minimum budgeting requirements for access, in-home,
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congregate, and home delivered meals services, as specified in Division of Aging and Adult
Services budget instructions issued to the County. If a budget revision will cause the County to
fall below minimum budgeting requirements for any of the aforementioned services, as
specified in Division of Aging and Adult Services budgeting instructions issued to the County,
the grants administrator for the County shall obtain written approval for the revision from the
Area Agency prior to implementation by the community service provider, so as to assure that
regional minimum budgeting requirements for the aforementioned services will be met.
Unless community services providers have been given the capacity to enter data into the Aging
Resources Management System (ARMS),Area Agencies on Aging are responsible for entering
amended service data into the Division of Aging Management Information System, as specified
in the N.C. Division of Aging and Adult Services Home and Community Care Block Grant
Procedures Manual for Community Service Providers,revised February 17, 1997.
8. Monitoring. This Agreement will be monitored to assure that services are being provided as
stated in the Division of Aging and Adult Service monitoring Policies and Procedures at
http://www.ncdhhs.gov/aging/monitor/mpolicy.htm .
The monitoring of services provided under this Agreement shall be carried out by the Area
Agency on Aging in accordance with its Assessment Plan and as specified in Administrative
Letter 12-08 located at http://ncdhhs.gov/aging/admltrs/2012/DAAS-012-08.pdf. As of July 1,
2012, DAAS Program Compliance Representatives (PCRs) are no longer monitoring HCCBG
services provided through county departments of social services.
Counties and community service providers will receive a written report of monitoring findings
in accordance with procedures established in Section 308 of the AAA Policies and Procedures
Manual (7/1/03 and revised 10/1/09). Any areas of non-compliance will be addressed in a
written corrective action plan with the community service provider.
9. Disputes and Appeals. Any dispute concerning a question of fact arising under this Agreement
shall be identified to the designated grants administrator for the Area Agency. In accordance
with Lead Regional Organization(LRO)policy, a written decision shall be promptly furnished
to the designated grants administrator for the County.
The decision of the LRO is final unless within twenty(20) days of receipt of such decision the
Chairman of the Board of Commissioners furnishes a written request for appeal to the Director
of the North Carolina Division of Aging and Adult Services, with a copy sent to the Area
Agency. The request for appeal shall state the exact nature of the complaint. The Division of
Aging and Adult Services will inform the Chairman of the Board of Commissioners of its
appeal procedures and will inform the Area Agency that an appeal has been filed. Procedures
thereafter will be determined by the appeals process of the Division of Aging and Adult
Services. The state agency address is as follows:
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Director
North Carolina Division of Aging and Adult Services
2101 Mail Service Center
693 Palmer Drive
Raleigh,North Carolina 27699-2101
10. Termination for Cause. If through any cause, the County shall fail to fulfill in a timely and
proper manner its obligations under this Agreement, or the County has or shall violate any of
the covenants, agreements,representations or stipulations of this Agreement, the Area Agency
shall have the right to terminate this Agreement by giving the Chairman of the Board of
Commissioners written notice of such termination no fewer than fifteen(15) days prior to the
effective date of termination. In such event, all finished documents and other materials
collected or produced under this Agreement shall at the option of the Area Agency,become its
property. The County shall be entitled to receive just and equitable compensation for any work
satisfactorily performed under this Agreement.
11. Audit. The County agrees to have an annual independent audit in accordance with North
Carolina General Statutes,North Carolina Local Government Commission requirements,
Division of Aging and Adult Services Program Audit Guide for Aging Services and Federal
Office of Budget and Management(OMB) Circular A-133.
Community service providers, as specified in paragraph one (1), who are not units of local
government or otherwise subject to the audit and other reporting requirements of the Local
Government Commission are subject to audit and fiscal reporting requirements, as stated in NC
General Statute 143C-6-22 and 23 and OMB Circular A-133, where applicable. Applicable
community service providers must send a copy of their year-end financial statements, and any
required audit,to the Area Agency on Aging. Home and Community Care Block Grant
providers are not required to submit Activities and Accomplishments Reports. For-profit
corporations are not subject to the requirements of OMB Circular A-133,but are subject to NC
General Statute 143C-6-22 and 23 and Yellow Book audit requirements, where applicable.
Federal funds may not be used to pay for a Single or Yellow Book audit unless it a federal
requirement. State funds will not be used to pay for a Single or Yellow Book audit if the
provider receives less than$500,000 in state funds. The Department of Health and Human
Services will provide confirmation of federal and state expenditures at the close of the state
fiscal year. Information on audit and fiscal reporting requirements can be found at
https://www.ncgrants.gov/NCGrants/PublicReportsRegulations.jsp.
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The following provides a summary of reporting requirements under NCGS 143 C-6-22 and 23
and OMB Circular A-133 based upon funding received and expended during the service
provider's fiscal year.
Annual Expenditures Report Required to AAA Allowable Cost for Reporting
• Less than$25,000 in Certification form and State N/A
State or Federal funds Grants Compliance Re-
porting<$25,000 (item# 11,
Activities and Accomplishments
does not have to be completed)
OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
• Greater than$25,000 Certification form and Schedule of N/A
and less that$500,000 Grantee Receipts>$25,000 and
in State or Federal Funds Schedule of Receipts and Expendi-
tures
OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
• $500,00+in State funds Audited Financial Statement in May use State funds,but
and Federal pass through compliance with GAO/GAS (i.e. not Federal Funds
in an amount less than Yellow Book)
$500,000
• $500,000+in State funds Audited Financial Statement in May use State and Federal
and $500,000+in Federal compliance with OMB Circular funds
pass through funds (i.e. A-133 (i.e. Single Audit)
at least$1,000,000)
• Less than$500,000 in State Audited Financial Statement in May use Federal funds,
funds and $500,000+in compliance with OMB Circular but not State funds.
Federal pass through funds A-133 (i.e. Single Audit)
12. Audit/Assessment Resolutions and Disallowed Cost. It is further understood that the
community service providers are responsible to the Area Agency for clarifying any audit
exceptions that may arise from any Area Agency assessment, county or community service
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provider single or financial audit, or audits conducted by the State or Federal Governments. In
the event that the Area Agency or the Department of Health and Human Services disallows any
expenditure made by the community service provider for any reason, the County shall promptly
repay such funds to the Area Agency once any final appeal is exhausted in accordance with
paragraph nine(9). The only exceptions are if the Area Agency on Aging is designated as a
community service provider through the County Funding Plan or, if as a part of a procurement
process, the Area Agency on Aging enters into a contractual agreement for service provision
with a provider which is in addition to the required County Funding Plan formats. In these
exceptions,the Area Agency is responsible for any disallowed costs. The County or Area
Agency on Aging can recoup any required payback from the community service provider in the
event that payback is due to a community service provider's failure to meet OMB Circular A-
122 requirements, requirements of A-110, requirements of 45CFR, Part 1321, and 45CFR, Part
92, or state eligibility requirements as specified in policy.
13. Indemnity. The County agrees to indemnify and save harmless the Area Agency, its agents, and
employees from and against and all loss, cost, damages, expenses, and liability arising out of
performance under this Agreement to the extent of errors or omissions of the County, to the
extent provided by North Carolina law.
14. Equal Employment Opportunity and Americans With Disabilities Act Compliance. Both the
County and community service providers, as identified in paragraph one(1), shall comply with
all federal and state laws relating to equal employment opportunity and accommodation for
disability.
15. Data to be Furnished to the County. All information which is existing,readily available to the
Area Agency without cost and reasonably necessary, as determined by the Area Agency's staff,
for the performance of this Agreement by the County shall be furnished to the County and
community service providers without charge by the Area Agency. The Area Agency, its agents
and employees, shall fully cooperate, with the County in the performance of the County's duties
under this Agreement.
16. Rights in Documents, Materials and Data Produced. The County and community service
providers agree that at the discretion of the Area Agency, all reports and other data prepared by
or for it under the terms of this Agreement shall be delivered to,become and remain, the
property of the Area Agency upon termination or completion of the work. Both the Area
Agency and the County shall have the right to use same without restriction or limitation and
without compensation to the other. For the purposes of this Agreement, "data" includes
writings, sound recordings, or other graphic representations, and works of similar nature. No
reports or other documents produced in whole or in part under this Agreement shall be the
subject of an application for copyright by or on behalf of the County.
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17. Interest of the Board of Commissioners. The Board of Commissioners covenants that neither
the Board of Commissioners nor its agents or employees presently has an interest,nor shall
acquire an interest, direct or indirect, which conflicts in any manner or degree with the
performance of its service hereunder, or which would prevent, or tend to prevent, the
satisfactory performance of the service hereunder in an impartial and unbiased manner.
18. Interest of Members of the Area Agency, Lead Regional Organization, and Others. No officer,
member or employee of the Area Agency or Lead Regional Organization, and no public official
of any local government which is affected in any way by the Project, who exercises any
function or responsibilities in the review or approval of the Project or any component part
thereof, shall participate in any decisions relating to this Agreement which affects his personal
interest or the interest of any corporation,partnership or association in which he is, directly or
indirectly, interested; nor shall any such persons have any interest, direct or indirect, in this
Agreement or the proceeds arising there from.
19. Officials not to Benefit. No member of or delegate to the Congress of the United States of
America, resident Commissioner or employee of the United States Government, shall be
entitled to any share or part of this Agreement or any benefits to arise here from.
20. Prohibition Against Use of Funds to Influence Legislation. No part of any funds under this
Agreement shall be used to pay the salary or expenses of any employee or agent acting on
behalf of the County to engage in any activity designed to influence legislation or
appropriations pending before Congress.
21. Applicable Law. This Agreement is executed and is to be performed in the State of North
Carolina, and all questions of interpretation and construction shall be construed by the laws of
such State.
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22. Payment to Community Service Providers by the Area Agency on Aging. The
County authorizes the Area Agency on Aging, in lieu of the County Finance
Officer, to provide interim and reimbursement payments to community service
providers as prescribed in paragraphs 6(a) and(c) of this Agreement. Services
applicable to this authorization are as follows:
Community Service Provider Service
Senior Care of Orange County, Inc. Adult Day Health Care
This authorization by the County shall be in compliance with requirements set
forth in the North Carolina Budget and Fiscal Control Act. The County Finance
Officer shall establish controls to account for the receipt and expenditure of Home
and Community Care Block Grant Funds.
23. Contractors and subcontractors of Older Americans Act funds are prohibited from discharging,
Demoting, or otherwise discriminating against an employee for whistle blowing as codified in
48 CRF Ch. 1 3.908.
http://www.gpo.gov/fdsysipkq/CFR-2013-title48-voI l/pdf/CFR-2013-titl e48-volt.pdf
24. By signature on the attached documents, the Federal Certifications and State Certifications, the
agency and its subcontractors certify compliance with federal requirements regarding debarment,
suspension, drug-free workplace and lobbying and; state requirements regarding verification of
work authorization, retail tax collection, E-verify laws, contracts with foreign vendors, and
eligible vendors.
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In witness whereof, the Area Agency and the County have executed this Agreement as of the day first
written above.
Orange County
Attest:
�By: '
C airman, : :. •;f Co • issioners
Triangle J Council of Governments Area Agency on Aging
Attest: 7-
- �w -4 �ill BJ• 1"/Kir6'.--)by(M.,..U',' J
Joan M. Pellettier veers
Dir-ctor, Area Agency on Aging utive Director,
uncil of Governments
(Lead Regional Organization)
Provision for payment of the monies to fall due under this Agreement within the current fiscal year
have been made by appropriation duly authorized as required by the Local Government Budget and
Fiscal Control Act.
BY: (--)r, l_ Y, P 4_
Judy A. Weller
Finance Director
Triangle J Council of Governments
(Lead Regional Organizational)
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FEDERAL CERTIFICATIONS
The undersigned states that:
1. He or she is the duly authorized representative of the Contractor named below;
2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, 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 Contractor 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 Contractor has not
made, and has no 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 Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
Signature Title
Contractor Name Date
[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page]
I. Certification Regarding Nondiscrimination
The Contractor 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 Contractor certifies that it will 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 Contractor'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:
i. The dangers of drug abuse in the workplace;
ii. The Contractor's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. 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:
i. Abide by the terms of the statement; and
ii. 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)(ii) 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)(ii), with respect to
any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and including
termination; or
ii. 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 (f).
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):
Address
Street
City, State, Zip Code
Street
City, State, Zip Code
3. Contractor 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.
Ill. 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 Contractor certifies that it will comply with the requirements of the Act. The Contractor 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 Contractor.]
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
1. 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.
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.
V. Certification Regarding Lobbying
The Contractor 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 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, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative
agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this 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 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. 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
Department of Transportation, United States Coast Guard.
level below agency name, if known. For example, epa nt p ,
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
9 9 P P � 9
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
El c. cooperative agreement ❑ c. Post-Award
❑ d. loan For Material Change Only:
❑ e. loan guarantee
❑ 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:
❑ 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, Ml): different from No. 10a.) (last name, first name, Ml):
(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
Cl b. one-time fee
12. Form of Payment(check all that apply): ❑ c. commission
❑ d. contingent fee
❑ a. cash ❑ e. deferred
❑ 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.
Authorized for Local Reproduction
Standard Form-LLL
State Certifications
Contractor Certifications Required by North Carolina Law
Instructions
The person who signs this document should read the text of the statutes listed below and consult with counsel and other
knowledgeable persons before signing.
• The text of Article 2 of Chapter 64 of the North Carolina General Statutes can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter 64/Article 2.pdf
• The text of G.S. 105-164.8(b) can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter 105/GS 105-164.8.pdf
• The text of G.S. 143-48.5 (S.L. 2013-418, s. 2.(d))can be found online at:
http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H786v6.pdf
• The text of G.S. 143-59.1 can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter 143/GS 143-59.1.pdf
• The text of G.S. 143-59.2 can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter 143/GS 143-59.2.pdf
• The text of G.S. 147-33.95(g) (S.L. 2013-418, s. 2.(e))can be found online at:
http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H786v6.pdf
Certifications
(1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(g), the undersigned hereby certifies that the Contractor named
below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC
General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to
verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link:
www.uscis.qov
(2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an
"ineligible Contractor"as set forth in G.S. 143-59.1(a) because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of
Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or
more of the conditions of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
❑ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven
country" as set forth in G.S. 143-59.1(c)(2)after December 31, 2001; or
❑ The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven country"
as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the
principal market for the public trading of the stock of the corporation incorporated in the tax haven
country.
(3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or
owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A
of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years
immediately prior to the date of the bid solicitation.
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
Contractor Certifications Required by North Carolina Law Page 1 of 2
(b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the
Contractor; and
(c) He or she understands that any person who knowingly submits a false certification in response to the
requirements of G.S. 143-59.1 and -59.2 shall be guilty of a Class I felony.
Contractor's Name
Signature of Contractor's Authorized Agent Date
Printed Name of Contractor's Authorized Agent Title
Signature of Witness Title
Printed Name of Witness Date
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date
this document immediately thereafter.
Contractor Certifications Required by North Carolina Law Page 2 of 2