HomeMy WebLinkAbout2015-194 Aging - NC Dept. of Insurance, Division of SHIIP grant funds —Please return this copy to the Clerk to the Board's —
STATE OF NORTH CAROLINA
office for permanent agenda file.
COUNTY OF WAKE
This Contract and its attachments shall be completed and returned to the Agency within 45 days of receiving the
electronic document in order for the Agency to process the award and provide funds to the Grantee. The Grantee
shall provide the agency with progress reports and a final report detailing the Grantee's use of State funds.
This Contract is entered into by and between the North Carolina Department of Insurance,Division of SHIM
hereinafter referred to as the"Agency", and Oran eg .County;North'Carolina located in Orange county,
hereinafter referred to as the"Grantee",referred to collectively as the"Parties".
1. Contract Documents: This Contract shall consist of the following documents, incorporated herein by
reference:
(1) This Contract;
(2) General Terms and Conditions for Public Sector Contracts(Attachment A)
(3) Statement of Work(Attachment B)
(4) Line Item Budget and Budget Narrative(Attachment C)
(5) Certifications Regarding,Drug-Free Work-Place; Lobbying; and Debarment, Suspension and Other
Responsibility Matters (Attachment D)
These documents constitute the entire agreement between the Parties and supersede all prior 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 is effective 10/1/2014 and terminates on 9/30/2015.
4. Grantee's Duties: The Grantee shall provide the services as described in Attachment B with the terms of
this Contract and in accordance with the approved budget in Attachment C. The Grantee shall maintain and
make available all records,papers,vouchers,books,correspondence or other documentation or evidence at
reasonable times for review, inspection or audit by duly authorized officials of the Agency,the North
Carolina State Auditor,or applicable federal agencies. The Grantee shall submit to the Agency all plans,
reports, documents or other products that the Agency may require, in the form specified by the Agency,
including at the least following:
A) A final budget report of expenses incurred during the contract period date;
B) A mid-year report of the contracted activities of the Grantee due by April 30,2015;
C) A final comprehensive report within sixty(60)days of the project end date; due on or before
November 30,2015.
5. Agency's Duties: The Agency shall reimburse the Grantee for the costs of services and activities described
in Attachment B and in accordance with the approved budget in Attachment C. The Agency shall monitor
the Grantee for compliance with the terms of this Contract; and shall specify all reports and other
deliverables required from the Grantee.
j
The Agency shall pay the Grantee in the manner and in the amounts specified in the Contract Documents.
The total amount paid by the Agency to the Grantee under this Contract shall not exceed$'f.47735. This
amount consists of$1.773:: ; CFDA#93.779.
[X] a. There are no matching requirements from the Grantee.
[ ] b. The Grantee's matching requirement is $ which shall consist of:
[ ] In-kind [ ] Cash
[ ] Cash and In-kind [ ] Cash and/or In-kind
The contributions from the Grantee shall be source from non-federal funds.
The total contract amount is$1 T 1:, .
6. Conflict of Interest Policy: The Agency has determined that this Contract is not subject to NCGS 14-C-6-
22 &23.
7. Reversion of Unexpended Funds: Any unexpended grant funds shall revert to the Agency upon
termination of this Contract.
8. Grants: The Grantee has the responsibility to ensure that all sub-grantees, if any, provide all information
necessary to permit the Grantee to comply with the terms and conditions set forth in this Contract.
9. Payment Provisions: As provided in NCGS 143C-21 this Contract is an annual appropriation of$100,000
or less to or for the use of a non-profit corporation and payment shall be made in a single annual payment.
10. 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, address,telephone number and fax number of the Parties'respective
initial Contract Administrators are set out below. Either Party may change the name,address,telephone
number and fax number of its Contract Administrator by giving timely written notice to the other Party.
For the Agency: For the Grantee:
R.Van Braxton,Deputy Commissioner Beverly Shuford
SHIIP Division 2551 Homestead Rd
11 South Boylan Avenue Chapel Hill.NC 27516
Raleigh,NC 27603 Phone 91 = 4
919-807-6900 Fax 9I;9��8�°'�0�
919-807-6901
11. Supplementation of Expenditures of Public Funds: The Grantee assures that funds received under this
Contract shall be used only to supplement,not to supplant,the total amount of federal, state and local public
funds the Grantee otherwise expends for SHIIP services and related programs. Funds received under this
Contract shall be used to provide additional public funding for such services;the funds shall not be used to
reduce the Grantee's total expenditure of other public funds for such services.
12. Disbursements: As a condition of this Contract,the Grantee acknowledges and agrees to make
disbursements in accordance with the following requirements:
a. Implement adequate internal controls over disbursements;
b. Pre-audit all vouchers presented for payment to determine:
• Validity and accuracy of payment;
• Payment due date;
• Adequacy of documentation supporting payment;and
Page 2 of 15
• Legality of disbursement;
C. Assure adequate control of signature stamps/plates;
d. Assure adequate control of negotiable instruments; and
e. Implement procedures to ensure that the account balance is solvent and reconcile the account
monthly.
13. Outsourcing: The Grantee certifies that it has identified to the Agency all jobs related to the Contract that
have been outsourced to other countries, if any. Grantee further agrees that it will not outsource any such
jobs during the term of this Contract without providing notice to the Agency.
14. Executive Order#24: NCGS 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any
State Employee of any gift from anyone with a contract with the State, or from any person seeking to do
business with the State. By execution of any response in this procurement,you attest,for your entire
organization and its employees or agents,that you are not aware that any such gift has been offered,
accepted,or promised by any employees of your organization.
15. Audit: The Agency reserves the right to conduct an audit through the NCSMP Program Director.
16. Federal Certifications: The Grantee agrees to execute the following federal certifications that are attached
to this agreement(applicable when receiving federal funds).
A. Certification Regarding Lobbying.
B. Certification Regarding Department.
C. Certification Regarding Drug-Free Workplace Requirements.
Page 3 of 15
17. Signature Warranty: The undersigned represent and warrant that they are authorized to bind their
principals to the terms of this agreement.
In witness whereof,the Grantee and the Agency have executed this Agreement with one original,which is
retained by Agency.
Orangetounty,Norfn Carolina Witness
BY:
7niilf.0 .�,�n, ' !SSA _ r San
Printed Name Printed Name
DATE: �13
Division of S11II1?
BY: 1 L--
R.Van Braxton
Deputy Commissioner
DATE:
Contract is not executed until last signature is obtained.
The Agency and the Grantee agree and understand that this contract is considered executed on the latest date of either
the last signature on this agreement or the date of Department of Insurance's procurement electronic approval.
i
Page 4 of 15
Attachment A
General Terms and Conditions
DEFINITIONS individuals for Medicare and Medicaid patient
unless indicated otherwise from the context, the services.
following terms shall have the following meanings in (8) "Financial Statement" means a report
this Contract. All definitions are from 9 NCAC providing financial statistics relative to a given
3M.0102 unless otherwise noted. If the rule or statute part of an organization's operations or status.
that is the source of the definition is changed by the (9) "Grant" means financial assistance provided
adopting authority, the change shall be incorporated by an agency, grantee, or subgrantee to carry
herein. out activities whereby the grantor anticipates
(1) "Agency" (as used in the context of the no programmatic involvement with the grantee
definitions below) shall mean and include or subgrantee during the performance of the
every public office, public officer or official grant.
(State or local, elected or appointed), (10) "Grantee" has the meaning in NCGS 143C-6-
institution, board, commission, bureau, 23(a)(2): a non-State entity that receives a
council, department, authority or other unit of grant of State funds from a State agency,
government of the State or of any county,unit, department, or institution but does not include
special district or other political subagency of any non-State entity subject to the audit and
government. For other purposes in this other reporting requirements of the Local
Contract, "Agency" shall mean the entity Government Commission. For other purposes
identified as one of the parties hereto. in this Contract, "Grantee" shall mean the
(2) "Audit" means an examination of records or entity identified as one of the parties hereto.
financial accounts to verify their accuracy. (11) "Grantor" means an entity that provides
(3) "Certification of Compliance" means a report resources,generally financial,to another entity
provided by the Agency to the Office of the in order to achieve a specified goal or
State Auditor that states that the Grantee has objective.
met the reporting requirements established by (12) "Non-State Entity" has the meaning in NCGS
this Subchapter and included a statement of 143C-1-1(d)(18): Any of the following that is
certification by the Agency and copies of the not a State agency: An individual, a firm, a
submitted grantee reporting package. partnership, an association, a county, a
(4) "Compliance Supplement" refers to the North corporation, or any other organization acting
Carolina State Compliance Supplement, as a unit. The term includes a unit of local
maintained by the State and Local government and public authority.
Government Finance Agency within the North (13) "Public Authority" has the meaning in NCGS
Carolina Department of State Treasurer that 143C-1-1(d)(22): A municipal corporation
has been developed in cooperation with that is not a unit of local government or a local
agencies to assist the local auditor in governmental authority, board, commission,
identifying program compliance requirements council, or agency that (i) is not a municipal
and audit procedures for testing those corporation and (ii) operates on an area,
requirements. regional, or multiunit basis, and the budgeting
(5) "Contract" means a legal instrument that is and accounting systems of which are not fully
used to reflect a relationship between the a part of the budgeting and accounting systems
agency, grantee,and subgrantee. of a unit of local government.
(6) "Fiscal Year" means the annual operating year (14) "Single Audit"means an audit that includes an
of the non-State entity. examination of an organization's financial
(7) "Financial Assistance" means assistance that statements, internal controls, and compliance
non-State entities receive or administer in the with the requirements of Federal or State
form of grants, loans, loan guarantees, awards.
property (including donated surplus property), (15) "Special Appropriation"means a legislative act
cooperative agreements, interest subsidies, authorizing the expenditure of a designated
insurance, food commodities, direct amount of public funds for a specific purpose.
appropriations, and other assistance. Financial (16) "State Funds" means any funds appropriated
assistance does not include amounts received by the North Carolina General Assembly or
as reimbursement for services rendered to collected by the State of North Carolina. State
Page 5 of 15
funds include federal financial assistance information necessary to permit the Grantee to comply
received by the State and transferred or with the standards set forth in this Contract.
disbursed to non-State entities. Both Federal
and State funds maintain their identity as they Assignment: No assignment of the Grantee's
are subgranted to other organizations. obligations or the Grantee's right to receive payment
Pursuant to NCGS 143C-6-23(a)(1), the terms hereunder shall be permitted. However, upon written
"State grant funds" and "State grants" do not request approved by the issuing purchasing authority,the
include any payment made by the Medicaid State may:
program, the Teachers' and State Employees' (a) Forward the Grantee's payment check(s)directly
Comprehensive Major Medical Plan, or other to any person or entity designated by the
similar medical programs. Grantee, or
(17) "Subgrantee" has the meaning in NCGS (b) Include any person or entity designated by
143C-6-23(a)(3): a non-State entity that Grantee as a joint payee on the Grantee's
receives a grant of State funds from a grantee payment check(s).
or from another subgrantee but does not In no event shall such approval and action obligate the
include any non-State entity subject to the State to anyone other than the Grantee and the Grantee
audit and other reporting requirements of the shall remain responsible for fulfillment of all contract
Local Government Commission. obligations.
(18) "Unit of Local Government" has the meaning
in NCGS 143C-1-1(d)(29): A municipal Beneficiaries: Except as herein specifically provided
corporation that has the power to levy taxes, otherwise, this Contract shall inure to the benefit of and
including a consolidated city-county as be binding upon the parties hereto and their respective
defined by NCGS 160B-2(1), and all boards, successors.It is expressly understood and agreed that the
agencies, commissions, authorities, and enforcement of the terms and conditions of this Contract,
institutions thereof that are not municipal and all rights of action relating to such enforcement,
corporations. shall be strictly reserved to the Agency and the named
Grantee. Nothing contained in this document shall give
Relationships of the Parties or allow any claim or right of action whatsoever by any
other third person. It is the express intention of the
Independent Contractor: The Grantee is and shall be Agency and Grantee that any such person or entity, other
deemed to be an independent contractor in the than the Agency or the Grantee, receiving services or
performance of this Contract and as such shall be wholly benefits under this Contract shall be deemed an
responsible for the work to be performed and for the incidental beneficiary only.
supervision of its employees. The Grantee represents
that it has, or shall secure at its own expense, all Indemnity
personnel required in performing the services under this
agreement. Such employees shall not be employees of, Indemnification: The Grantee agrees to indemnify and
or have any individual contractual relationship with, the hold harmless the Agency, the State of North Carolina,
Agency. and any of their officers, agents and employees, from
any claims of third parties arising out of any act or
Subcontracting: The Grantee shall not subcontract any omission of the Grantee in connection with the
of the work contemplated under this Contract without performance of this Contract.
prior written approval from the Agency. Any approved
subcontract shall be subject to all conditions of this Default and Termination
Contract. Only the subcontractors or subgrantees
specified in the contract documents are to be considered Termination by Mutual Consent: The Parties may
approved upon award of the contract. The Agency shall terminate this Contract by mutual consent with 60 days
not be obligated to pay for any work performed by any notice to the other party, or as otherwise provided by
unapproved subcontractor or subgrantee. The Grantee law.
shall be responsible for the performance of all of its
subgrantees and shall not be relieved of any of the duties Termination Without Cause: The Agency may
-nd responsibilities of this Contract. terminate this contract without cause by giving 60 days
written notice to the Contractor. In that event, all
Subgrantees: The Grantee has the responsibility to finished or unfinished deliverable items prepared by the
ensure that all subgrantees, if any, provide all Contractor under this contract shall, at the option of the
Agency, become its property and the Contractor shall be
Page 6 of 15
entitled to receive just and equitable compensation for determines that some or all of the activities within the
any satisfactory work completed on such materials, scope of this contract are subject to the Health Insurance
minus any payment or compensation previously made. Portability and Accountability Act of 1996, P.L. 104-91,
as amended("HIPAA"), or its implementing regulations,
Zrmination for Cause: If, through any cause, the it will comply with the HIPAA requirements and will
Grantee shall fail to fulfill its obligations under this execute such agreements and practices as the Agency
Contract in a timely and proper manner, the Agency may require to ensure compliance.
shall have the right to terminate this Contract by giving
written notice to the Grantee and specifying the effective Executive Order#24: `By Executive Order 24, issued
date thereof. In that event, all finished or unfinished by Governor Perdue, and NCGS 133-32, it is unlawful
deliverable items prepared by the Grantee under this for any vendor or contractor ( i.e. architect, bidder,
Contract shall, at the option of the Agency, become its contractor, construction manager, design professional,
property and the Grantee shall be entitled to receive just engineer, landlord, offeror, seller, subcontractor,
and equitable compensation for any satisfactory work supplier, or vendor), to make gifts or to give favors to
completed on such materials, minus any payment or any State employee of the Governor's Cabinet Agencies
compensation previously made. Notwithstanding the (i.e., Administration, Commerce, Correction, Crime
foregoing provision, the Grantee shall not be relieved of Control and Public Safety, Cultural Resources,
liability to the Agency for damages sustained by the Environment and Natural Resources, Health and Human
Agency by virtue of the Grantee's breach of this Services, Juvenile Justice and Delinquency Prevention,
agreement, and the Agency may withhold any payment Revenue, Transportation, and the Office of the
due the Grantee for the purpose of setoff until such time Governor). This prohibition covers those vendors and
as the exact amount of damages due the Agency from contractors who have a contract with a governmental
such breach can be determined. agency; or have performed under such a contract within
the past year; or anticipate bidding on such a contract in
Waiver of Default: Waiver by the Agency of any the future.
default or breach in compliance with the terms of this
Contract by the Grantee shall not be deemed a waiver of For additional information regarding the specific
-ny subsequent default or breach and shall not be requirements and exemptions, vendors and contractors
anstrued to be modification of the terms of this are encouraged to review Executive Order 24 and NCGS
Contract unless stated to be such in writing, signed by an Sec. 133-32.
authorized representative of the Agency and the Grantee
and attached to the contract. Executive Order 24 also encouraged and invited other
State Agencies to implement the requirements and
Availability of Funds: The parties to this Contract prohibitions of the Executive Order to their agencies.
agree and understand that the payment of the sums Vendors and contractors should contact other State
specified in this Contract is dependent and contingent Agencies to determine if those agencies have adopted
upon and subject to the appropriation, allocation, and Executive Order 24."
availability of funds for this purpose to the Agency.
Intellectual Property Rights
Force Majeure: Neither party shall be deemed to be in
default of its obligations hereunder if and so long as it is Copyrights and Ownership of Deliverables: All
prevented from performing such obligations by any act deliverable items produced pursuant to this Contract are
of war, hostile foreign action, nuclear explosion, riot, the exclusive property of the Agency. The Grantee shall
strikes, civil insurrection, earthquake,hurricane,tornado, not assert a claim of copyright or other property interest
or other catastrophic natural event or act of God. in such deliverables.
Survival of Promises: All promises, requirements, Compliance with Applicable Laws
terms, conditions, provisions, representations,
guarantees, and warranties contained herein shall survive Compliance with Laws: The Grantee shall comply
the contract expiration or termination date unless with all laws, ordinances, codes, rules, regulations, and
specifically provided otherwise herein, or unless licensing requirements that are applicable to the conduct
superseded by applicable federal or state statutes of of its business, including those of federal, state,and local
.mitation. agencies having jurisdiction and/or authority.
Health Insurance Portability and Accountability Act
(EUPAA): The Contractor agrees that, if the Agency
Page 7 of 15
Equal Employment Opportunity: The Grantee shall Contract, to the exclusive jurisdiction of the courts of
comply with all federal and state laws relating to equal North Carolina and agrees, solely for such purpose, that
employment opportunity. the exclusive venue for any legal proceedings shall be
Wake County, North Carolina. The place of this
Confidentiality Contract and all transactions and agreements relating to
it, and their situs and forum, shall be Wake County,
Confidentiality: Any information, data, instruments, North Carolina, where all matters, whether sounding in
documents, studies or reports given to or prepared or contract or tort, relating to the validity, construction,
assembled by the Grantee under this agreement shall be interpretation,and enforcement shall be determined.
kept as confidential and not divulged or made available
to any individual or organization without the prior Amendment: This Contract may not be amended orally
written approval of the Agency. The Grantee or by performance. Any amendment must be made in
acknowledges that in receiving, storing, processing or written form and executed by duly authorized
otherwise dealing with any confidential information it representatives of the Agency and the Grantee.
will safeguard and not further disclose the information
except as otherwise provided in this Contract. Severability: In the event that a court of competent
jurisdiction holds that a provision or requirement of this
Oversight Contract violates any applicable law, each such
provision or requirement shall continue to be enforced to
Access to Persons and Records: The State Auditor the extent it is not in violation of law or is not otherwise
shall have access to persons and records as a result of all unenforceable and all other provisions and requirements
contracts or grants entered into by State agencies or of this Contract shall remain in full force and effect.
political subdivisions in accordance with NCGS 147-
64.7. Additionally, as the State funding authority, the Headings: The Section and Paragraph headings in these
Agency and all applicable federal agencies or their General Terms and Conditions are not material parts of
agents shall have access to persons and records as a the agreement and should not be used to construe the
result of all contracts or grants entered into by State meaning thereof.
,genies or political subdivisions.
Time of the Essence: Time is of the essence in the
Record Retention: Records shall not be destroyed, performance of this Contract.
purged or disposed of without the express written
consent of the Agency. State basic records retention Key Personnel: The Contractor shall not replace any of
policy requires all grant records to be retained for a the key personnel assigned to the performance of this
minimum of five years or until all audit exceptions have contract without the prior written approval of the
been resolved, whichever is longer. If the contract is Agency. The term "key personnel" includes any and all
subject to federal policy and regulations,record retention persons identified as such in the contract documents and
may be longer than five years since records must be any other persons subsequently identified as key
retained for a period of three years following submission personnel by the written agreement of the parties.
of the final Federal Financial Status Report, if
applicable, or three years following the submission of a Care of Property: The Grantee agrees that it shall be
revised final Federal Financial Status Report. Also, if responsible for the proper custody and care of any
any litigation, claim, negotiation, audit, disallowance property furnished to it for use in connection with the
action, or other action involving this Contract has been performance of this Contract and will reimburse the
started before expiration of the five-year retention period Agency for loss of, or damage to, such property. At the
described above, the records must be retained until termination of this Contract, the Grantee shall contact
completion of the action and resolution of all issues the Agency for instructions as to the disposition of such
which arise from it, or until the end of the regular five- property and shall comply with these instructions.
year period described above,whichever is later.
Travel Expenses:Reimbursement to the Grantee for
Miscellaneous travel mileage,meals, lodging and other travel expenses
incurred in the performance of this Contract shall be
'.hoice of Law: The validity of this Contract and any of reasonable and supported by documentation. State rates
.s terms or provisions, as well as the rights and duties of should be used as guidelines. International travel shall
the parties to this Contract, are governed by the laws of not be reimbursed under this Contract.
North Carolina. The Grantee, by signing this Contract,
agrees and submits, solely for matters concerning this
Page 8 of 15
Sales/Use Tax Refunds: If eligible,the Grantee and all and use taxes from all reportable expenditures before the
subgrantees shall: (a)ask the North Carolina Department expenses are entered in their reimbursement reports.
of Revenue for a refund of all sales and use taxes paid by
*hem in the performance of this Contract, pursuant to Advertising: The Grantee shall not use the award of
CGS 105-164.14; and (b) exclude all refundable sales this Contract as a part of any news release or commercial
advertising.
i
I
Page 9 of 15
Attachment B
For the period 10/1/2014—9/30/2015
Statement of Work
Grantee: Orange.Coun�,r:North:Carolina
This statement should be a short summary describing what the Grantee does and how the Grantee will use these funds.
The terms of the contract between the SHIIP office and the agencies require local programs meet these goals for
SFY2015. The uses of these funds are not limited to but MUST include the following activities:
1) Expand Low Income Subsidy(LIS)outreach and enrollment in the county by conducting a minimum of two
enrollment clinics during the period 10/1/2014 through 9/30/2015; clinics are to be held in non-traditional
locations, i.e., library,church, senior housing complex,etc.;
2) Submit Client Counseling Contact and Public &Media Outreach(NPR)forms in a timely manner to the SHIM office
in Raleigh or through the SHIPTalk website;
3) Attend the SHIIP Coordinators'Training Conference being held June 24-26; attendance on the 24th thru the 26th is
mandatory for new coordinators; attendance on the 25th and 26th is mandatory for all coordinators.
SCOPE OF WORK:
(Maximum 2 pages)
l
�)Orange County SHIIP Coordinator and SHIIP volunteers will expand Low Income Subsidy(LIS)outreach and
enrollment in the county by conducting a minimum of two enrollment clinics during the period 10/1/2014 through
9/30/2015; clinics will be held in non-traditional locations, i.e.,library, church, senior housing complex,etc.
2)Orange County SHIIP Coordinator and SHIIP Volunteers will submit Client Counseling Contact and Public&Media
Outreach(NPR)forms in a timely manner to the SHIIP office in Raleigh or through the SHIPTalk website.
3)Orange County SHIIP Coordinator,Beverly Shuford will attend the SHIIP Coordinators'Training Conference being
held June 24-26,2015; understanding that attendance on the 25th and 26th is mandatory for all coordinators the
coordinator will attend on June 25-26,2015.
I
Page 10 of 15
SCOPE OF WORK: cont.
Page 11 of 15
Attachment C
For the period 10/1/2014—9/30/2015
Line Item Budget and Budget Narrative
Provide a budget and short narrative on the use of the funding amount reflected on the contract. Please provide details of
all expenses including routine charges. These expenditures may include telephone,postage, salary, equipment purchases,
internet services etc.
All budgets must be approved by the Agency.
Grantee Name: Orange County North Carolina
G.'rantee Name::`:gran e;Coun ;No rtitw°larolna ;
Budget Amount
Contractual
Construction
Supplies
Equipment 298.25
Other 1,250.00
Travel 225.00
Personnel
Fringe
Total 1,773.25
Narrative:
Equipment: Client appointment and counselor scheduling software
Other:Advertise Extra Help in Senior Times and on Transit buses
Travel: Attend the 2015 SHIIP Coordinators Conference in Greensboro,NC,June 25-26,2015
i
Page 12 of 15
Attachment D
Certifications Regarding,Drug-Free Work-Place; Lobbying; and
Debarment,Suspension and Other Responsibility Matters
1. Drug-Free Work-Place
The undersigned(authorized official)certifies that it will provide a drug-free workplace in accordance with the Drug-
Free Work-Place Act of 1988,45 CFR Part 76, subpart F. The certification set out below is a material representation
of fact upon which reliance will be placed when awarding the grant. False certification or violation of the certification
shall be grounds for suspension of payments, suspensions or termination of grants or government wide suspension or
debarment.
The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a)Publishing a statement notifying employees that the unlawful manufacture,distribution,dispensing,
possession,or use of a controlled substance is prohibited in the grantee's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
(b)Establishing an on-going drug-free awareness program to inform employees about—
(1)The dangers of drug abuse in the workplace;
(2)The grantee's policy of maintaining a drug-free workplace;
(3)Any available drug counseling,rehabilitation,and employee assistance programs; and
(4)The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c)Making it a requirement that each employee to be engaged in the performance of the grant be given a copy
of the statement required by paragraph(a); above;
(d)Notifying the employee in the statement required by paragraph(a)that,as a condition of employment
under the grant,the employee will—
(1)Abide by the terms of the statement;and
(2)Notify the employer in writing of his or her conviction for a violation of a criminal drug statute
occurring in the workplace no later than five calendar days after such conviction;
(e)Notifying the agency, in writing,within 10 calendar days after receiving notice under subparagraph(d)(2),
above,from an employee or otherwise receiving actual notice of such conviction. Employers of convicted
employees must provide notice, including position title,to Agency on whose grant activity the convicted
employee was working.
Notices shall include the identification number(s)of each affected grant;
(f)Taking one of the following actions,within 30 days of receiving notice under subparagraph(d)(2),above,
with respect to any employee who is so convicted—
(1)Taking appropriate personnel action against such an employee,up to and including termination,
consistent with the requirements of the Rehabilitation Act of 1973,as amended; or
(2)Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State,or local health, law enforcement,or other
appropriate agency;
(g)Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs(a),(b),(c),(d),(e), and(f).
The grantee certifies that, as a condition of the grant, it will not engage in the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance in conducting any activity with the grant.
Page 13 of 15
2. Lobbying
Title 31 of the United States Code, Section 1352, entitled"Limitation on use of appropriated funds to influence
-ertain Federal contracting and financial transactions,"generally prohibits recipients of Federal grants and cooperative
jeements from using Federal(appropriated)funds for lobbying the Executive or Legislative Branches of the Federal
Government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each
person who request or received a Federal grants or cooperative agreement must disclose lobbying undertaking with
non-Federal(non-appropriated)funds. These requirements apply to grants and cooperative agreements EXCEEDING
$100,000 in total costs(45 CFR Part93).
The undersigned(authorized official)certifies,to the best of his or her knowledge and belief,that:
(a)No Federal appropriated funds have been paid or will be paid,by or on behalf of the undersigned,to any
person for influencing or attempting to influence an officer or employee of any agency, a member of
Congress, any officer or employee of Congress,or an employee of a Member of Congress in connection with
the awarding of any Federal contract,the making of any Federal grant,the malting of any Federal loan,the
entering into of any cooperative agreement,and the extension,continuation,renewal,amendment,or
modification of any Federal grant, loan or cooperative agreement;
(b)If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency,a Member of Congress,an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
contract, grant, loan or cooperative agreement,the undersigned shall complete and submit Standard Form-
LLL, "Disclosure of Lobbying Activities,"in accordance with its instructions;
(c)The undersigned shall require that the language of this certification be included in the award documents
for all subawards at all tiers(including subcontracts, subgrants, contracts and contracts under grants, loans
r
and cooperative agreements)and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made
or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed
by section 1352,title 31,U.S. Code. Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,000 and not more than$100,000 for each such failure.
3. Debarment,Suspension and Other Responsibility Matters
NOTE: In accordance with 45 CFR Part 76,amended June 26, 1995,any debarment,suspension,proposed debarment
or other government wide exclusion initiated under the Federal Acquisition Regulation(FAR)on or after August 25,
1995, shall be recognized by and effective for Executive Branch agencies and participants as an exclusion under 45
CFR Part 76.
(a)Primary Covered Transactions
The undersigned(authorized official)certifies to the best of his or her knowledge and belief,that the
applicant,defined as the primary participant in accordance with 45 CFR Part 76, and its principals:
(1)are not presently debarred, suspended,proposed for debarment,declared ineligible,or voluntarily
excluded by any Federal department or agency;
(2)have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered
against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain,
or performing a public(Federal, State or local)transaction or contract under a public transaction;violation of
Federal or State antitrust statutes or commission of embezzlement,theft,forgery,bribery,falsification or
destruction of records,making false statements,or receiving stolen property;
Page 14 of 15
(3)are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(Federal,
State,or local)with commission of any of the offenses enumerated in paragraph(a)(2)of this certification; and
(4)have not within a 3-year period preceding this application/proposal had one or more public transactions
(Federal, State,or local)terminated for cause or default.
Should the applicant not be able to provide this certification,an explanation as to why should be placed under
the assurances page in the application package.
(b)Lower Tier Covered Transactions
The applicant agrees by submitting this proposal that it will include,without modification,the following clause titled
"Certification Regarding Debarment,Suspension,Ineligibility,and Voluntary Exclusion--Lower Tier
Covered Transaction"(Appendix B to 45 CFR Part 76) in all lower tier covered transactions(i.e.,transactions with
subgrantees and/or contractors)and in all solicitations for lower tier covered transactions:
Certification Regarding Debarment,Suspension,Ineligibility,and Voluntary Exclusion—Lower Tier
Covered Transactions
(1)The prospective lower tier participant certifies by submission of this proposal,that neither it nor its
principals is presently debarred,suspended,proposed for debarment, declared ineligible,or voluntarily
excluded from participation in this transaction by any Federal department or agency.
(2)Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal.
Signature of Authorized Certifying Official Title
Grantee Name Date Submitted
nge CountykNa th Garo i 2,. l>
Page 15 of 15