HomeMy WebLinkAbout2015-200 Aging - TJCOG Area Agency on Aging for County Based MIPPA Services DocuSign Envelope ID:871596FB-EB3F-4768-BC79-A5D9ADF74E87 d1z mow
Medicare Improvements for Patients and Providers Act(MIPPA)
Contract for the Provision of County Based MIPPA Services
This contract is hereby entered into by and between Triangle J Council of Governments Area
Agency on Aging (TJAAA), (the "Provider") and Orahge County.=North Carolina (the
"Subcontractor") (referred to collectively as the"Parties").The Subcontractor's federal tax
identification number is `
1. Contract Documents:
This contract consists of the following documents, which are incorporated herein by
reference:
a. This contract
b. General Terms and Conditions for Public Sector Contracts (Attachment A)
c. Statement of Work(Attachment B)
d. Line Item Budget and Budget Narrative(Attachment C)
e. 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 oral or written statements or agreements.
2. Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms
in the Contract Document with the highest relative precedence shall prevail. The order of
precedence shall be the order of documents as listed in the contract document section,with
the first-listed document having the highest precedence and the last-listed document
having the lowest precedence. If there are multiple contract amendments, the most recent
amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
3. Effective Period:
This contract shall be effective Mi
4. Subcontractor's Duties:
The Subcontractor shall provide the services as described in the Statement of Work
(Attachment B) and in accordance with the approved Line Item Budget and Budget
Narrative (Attachment C).
5. Provider's Duties:
The Provider shall pay the Subcontractor in the manner and in the amounts specified in the
contract documents. The total amount paid by the Provider to the Subcontractor under this
contract shall not exceed 0M. (CFDA#93.071) There are no matching requirements.
6. Conflict of Interest Policy/Statement:
The Provider 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 Provider upon termination of this contract.
DocuSign Envelope ID:871596FB-EB3F-4768-BC79-A5D9ADF74E87
8. Grants:
The Subcontractor has the responsibility to ensure that all sub-grantees, if any, provide all
information necessary to permit the Subcontractor to comply with the standards set forth in
this contract.
9. Payment Provisions:
Payment provisions of this contract are as follows:
a. An amount equal to one-half the total amount will be made upon final
execution of contract; and,
b. Pending compliance with monthly reporting requirements outlined in the
Statement of Work(Attachment B),the final one-half allotment will be
processed and paid upon receipt of the monthly compliance and budget
report due on _ r"
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, post office address, street address, telephone
number, fax number, and email address of the Parties' respective initial contract
administrators are set out below. Either Party may change the name, post office address,
street address,telephone number, fax number, or email address of its contract
administrator by giving a written 30 day notice to the other Party.
For the Provider:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER
MEANS
Joan M. Pellettier, Director,Area Agency on Aging
Triangle J Council of Governments Area Agency on Aging SAME
4307 Emperor Blvd.,Suite 110
Durham, NC 27703
Telephone: 919558-9398
Fax: 919 549-9390
Email:jpellettier @tjcog.org
For the Subcontractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER
MEANS
Beverly Shuford �lnfprmatlon;&Benefits�;$0.0 ialist Sarre
Orange County Department ph".gIng
2551 Homestead Rd:
Chapel:HiII; N C:278;16
Tellephone 9192 45,x}274
Fax;=9%968 2:09$(Seytnoitr Center.-Fa
ErtWl: bshuford.Qora jgeaoutit nC gov
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11. Supplementation of Expenditure of Public Funds:
The Subcontractor assures that funds received pursuant to this contract shall be used only
to supplement, not to supplant, the total amount of federal, state and local public funds that
the Subcontractor otherwise expends for contract 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 Subcontractor's total expenditure of
other public funds for such services.
12. Disbursements:
As a condition of this contract, the Subcontractor 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
• Legality of disbursement
c. Assure adequate control of signature stamps/plates;
d. Assure adequate control of negotiable instruments; and
e. Implement procedures to insure that account balance is solvent and reconcile the
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account monthly.
13. Outsourcing: The subcontractor agrees that it will not outsource any jobs related to this
contract without providing notice to the Provider.
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14. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to
the terms of this agreement.
15. Federal Certifications:
Individuals and Organizations receiving federal funds must ensure compliance with certain
certifications required by federal laws and regulations. The Subcontractor is hereby
complying with Certifications regarding Nondiscrimination, Drug-Free Workplace
Requirements, Environmental Tobacco Smoke, Debarment, Suspension, and Lobbying.
These assurances and certifications are Attachment D. The signature page is to be signed
by the Subcontractor's authorized representative.
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In Witness Whereof, the Subcontractor and the Provider have executed this contract in
duplicate originals, with one original being retained by each party.
Triangle J Council of Governments Area Agency on Aging (TJAAA)
Pellettier, Director AAA Date
Attest Or Witness
L4
Signature Date
AAA Pm Asso6ocl-e.
Printed Name Title
Subcontractor Name
E DceuSigned by:
6DVJAAL A�Myk 4/28/2015
%ftTaw Date
Bonnie Hammersley County Manager
Printed;Name Title
AttestOr Witness
r DocuSigned by:
t�tSSX QWSMA, 4/29/2015
Igna ure ... Date
Mel-issa Allison. Executive Assistant
Printed:Name Title
Provision for payment of the monies to fall due under this Agreement within the current federal
fiscal year have been made by appropriation duly authorized as required by the Local
Government Budget and Fiscal Control Act
BY: A- LfAA
Judy A. Weller
Finance Director
Triangle J Council of Governments
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Attachment A
GENERAL TERMS AND CONDITIONS
State laws relating to equal employment
Availability of Funds: The parties to this opportunity.
contract agree and understand that the payment
of the sums specified in this contract is dependent Health Insurance Portability and
and contingent upon and subject to the Accountability Act(HIPAA):The
appropriation, allocation, and availability of funds Subcontractor agrees that, if the Contractor
for this purpose to the Contractor from federal, determines that some or all of the activities
state and local sources. within the scope of this contract are subject to
the Health Insurance Portability and
Force Majeure: Neither party shall be deemed to Accountability Act of 1996, P.L. 104-91, as
be in default of its obligations hereunder if and so amended("HIPAA"), or its implementing
long as it is prevented from performing such regulations, it will comply with the HIPAA
obligations by any act of war, hostile foreign requirements and will execute such agreements
action, nuclear explosion, riot, strikes, civil and practices as the Contractor may require to
insurrection, earthquake, hurricane, tornado, or ensure compliance.
other catastrophic natural event or act of God.
Confidentiality
Survival of Promises: All promises,
requirements, terms, conditions, provisions, Confidentiality: Any information, data,
representations, guarantees, and warranties instruments, documents, studies or reports given
contained herein shall survive the contract to or prepared or assembled by the Subcontractor
expiration or termination date unless specifically under this agreement shall be kept as confidential
provided otherwise herein, or unless superseded and not divulged or made available to any
by applicable Federal or State statutes of individual or organization without the prior written
limitation. approval of the Contractor. The Subcontractor
acknowledges that in receiving, storing,
Intellectual Property Rights processing or otherwise dealing with any
confidential information it will safeguard and not
Copyrights and Ownership of Deliverables: All further disclose the information except as
deliverable items produced pursuant to this otherwise provided in this contract.
contract are the exclusive property of the
Contractor. The subcontractor shall not assert a Oversight
claim of copyright or other property interest in
such deliverables. Access to Persons and Records: The
Contractor, County, Area Agency on Aging,
Federal Intellectual Property Bankruptcy Division of Aging and Adult Services, other
Protection Act: The Parties agree that the authorized officials of the Contractor, funding
Contractor shall be entitled to all rights and authorities, the North Carolina State Auditor,
benefits of the Federal Intellectual Property and/or applicable federal agencies shall have
Bankruptcy Protection Act, Public Law 100-506, access to persons and records as a result of all
codified at 11 U.S.C. 365 (n) and any contracts or grants entered into by State agencies
amendments thereto. or political subdivisions in accordance with
General Statute 147-64.7. Additionally,as a State
Compliance with Applicable Laws funding authority, the Department of Health and
Human Services shall have access to persons and
Compliance with Laws: The Subcontractor shall records as a result of all contracts or grants
comply with all laws, ordinances, codes, rules, entered into by State agencies or political
regulations, and licensing requirements that are subdivisions.
applicable to the conduct of its business,including
those of federal, state,and local agencies having Record Retention: Records shall not be
jurisdiction and/or authority. destroyed, purged or disposed of without the
express written consent of the Contractor. State
Equal Employment Opportunity: The basic records retention policy requires all grant
Subcontractor shall comply with all federal and records to be retained for a minimum of five years
or until all audit exceptions have been resolved,
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whichever is longer. If the contract is subject to requirement of this contract violates any
federal policy and regulations, record retention applicable law, each such provision or
may be longer than five years since records must requirement shall continue to be enforced to the
be retained for a period of three years following extent it is not in violation of law or is not
submission of the final Federal Financial Status otherwise unenforceable and all other provisions
Report, if applicable, or three years following the and requirements of this contract shall remain in
submission of a revised final Federal Financial full force and effect.
Status Report. Also, if any litigation, claim,
negotiation, audit, disallowance action, or other Headings: The Section and Paragraph headings
action involving this Contract has been started in these General Terms and Conditions are not
before expiration of the five-year retention period material parts of the agreement and should not be
described above, the records must be retained used to construe the meaning thereof.
until completion of the action and resolution of all
issues which arise from it, or until the end of the Time of the Essence: Time is of the essence in
regular five-year period described above, the performance of this contract.
whichever is later.The record retention period for
Temporary Assistance for Needy Families(TANF) Key Personnel: The Contractor shall not replace
and MEDICAID and Medical Assistance grants any of the key personnel assigned to the
and programs must be retained for a minimum of performance of this contract without the prior
ten years. written notification of the Contractor. The term
"key personnel" includes any and all persons
Warranties and Certifications identified by as such in the contract documents
and any other persons subsequently identified as
Date and Time Warranty: The Subcontractor key personnel by the written agreement of the
warrants that the product(s) and service(s) parties.
furnished pursuant to this contract ("product"
includes, without limitation, any piece of Care of Property: The Subcontractor agrees that
equipment, hardware, firmware, middleware, it shall be responsible for the proper custody and
custom or commercial software, or internal care of any property furnished to it for use in
components,subroutines,and interfaces therein) connection with the performance of this contract
that perform any date and/or time data recognition and will reimburse the Contractor for loss of, or
function, calculation, or sequencing will support a damage to, such property. At the termination of
four digit year format and will provide accurate this contract, the Subcontractor shall contact the
date/time data and leap year calculations. This Area Agency on Aging for instructions as to the
warranty shall survive the termination or expiration disposition of such property and shall comply with
of this contract. these instructions.
Certification Regarding Collection of Taxes: Travel Expenses: Reimbursement to the
G.S. 143-59.1 bars the Secretary of Administration Subcontractor for travel mileage, meals, lodging
from entering into contracts with vendors that and other travel expenses incurred in the
meet one of the conditions of G.S. 105-164.8(b) performance of this contract shall not exceed the
and yet refuse to collect use taxes on sales of rates published in the applicable State rules.
tangible personal property to purchasers in North International travel shall not be reimbursed under
Carolina. The conditions include:(a)maintenance this contract.
of a retail establishment or office; (b)presence of
representatives in the State that solicit sales or Sales/Use Tax Refunds: If eligible, the
transact business on behalf of the vendor;and(c) Subcontractor and all subcontractors shall:(a)ask
systematic exploitation of the market by media- the North Carolina Department of Revenue for a
assisted, media-facilitated, or media-solicited refund of all sales and use taxes paid by them in
means. The Contractor certifies that it and all of the performance of this contract, pursuant to
its affiliates(if any)collect all required taxes. G.S. 105-164.14; and (b) exclude all refundable
Miscellaneous sales and use taxes from all reportable
expenditures before the expenses are entered in
Amendment: This contract may not be amended their reimbursement reports.
orally or by performance. Any amendment must
be made in written form and executed by duly Advertising: The Contractor shall not use the
authorized representatives of the Contractor. award of this contract as a part of any news
release or commercial advertising.
Severability: In the event that a court of
competent jurisdiction holds that a provision or
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DocuSign Envelope ID:871596FB-EB3F4768-BC79-A5D9ADF74E87
Attachment B
Statement of Work
Subcontractor: Oranae:County, North'Carolina
This statement should be short summary describing what the Subcontractor does and how the
Subcontractor will use these funds. The terms of the contract between TJAAAA and the
Subcontractor requires that these goals are met for the stated period. The uses of these funds
are not limited to but MUST include the following activities.
1) Conduct a minimum of two outreach activities in each county. A minimum of one
outreach activity must be planned in collaboration with a community partner(s)that
serves individuals with mental illness, and a minimum of one outreach activity must be
held that focuses on people who are aging and/or have disabilities other than mental
illness.
2) All outreach activities must include Relay for Extra Help materials provided by the Senor
Health Insurance Information (SHIIP) office.
3) Coordinate with local SHIIP sites and refer individuals who are likely eligible for LIS and
MSP.
4) Submit Client Counseling Contact forms for individual counseling and Public& Media
Outreach forms fro outreach events monthly to the TJAAA office for entering in the
national SHIPtalk reporting system.
5) Develop new partnerships for planning and conducting successful outreach events.
6) Encourage Medicare beneficiaries to participate in local disease prevention and wellness
activities.
7) Monthly reporting forms for contracted activities and expenses incurred are to be
submitted to electronically by the 1 Oth of each month for the month prior to Susan Reed
at susan.reed wake ov.com. A final report of expenses incurred is due on or before
EMBINOM
The following Scope of Work should address the ways the Subcontractor will accomplish the
above expectations and/or willingness to comply.
SCOPE OF WORK:
(maximum 2 pages)
1) Orange County SHIIP (OC SHIIP)will conduct a minimum of two outreach
activities including collaborating with at least one community partner that serves
individuals with mental illness to conduct an outreach event, and at least one
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DocuSign Envelope ID:871596FB-EB3F-4768-BC79-A5D9ADF74E87
outreach event that focuses on people who are aging and/or had disabilities
other than mental illness.
2) Relay for Extra Help materials will be used at all outreach events.
3) Coordinate with both Orange County SHIIP sites and NC SHIIP to refer individuals who
are likely eligible for LIS and MSP.
4) Enter Client Counseling Contact forms for individual counseling and Public& Media
Outreach forms for outreach events monthly in the national SHIPtalk reporting system
and provide TJAAA with reports.
5) Will continue to develop new partnerships for planning and conducting successful
outreach events with OC SHIIP counselors and community organizations.
6) OC SHIIP counselors will encourage Medicare beneficiaries to participate in local
disease prevention and wellness activities.
7) Monthly reporting forms for contracted activities and expenses incurred will be submitted
electronically by the 10th of each month for the month prior to Susan Reed at
susan.reeda-wakeaov.com. The final report of expenses incurred will be submitted by
November 10, 2015.
Attachment C
Line Item Budget and Budget Narrative
Using the budget line items listed below, please provide a budget and a short narrative on how
you plan to spend the funding amount reflected in the agreement. Allowable expenses include
telephone, postage, salary/stipends, equipment purchases, internet services, etc. New CMS
regulations stipulate that federal dollars cannot be used to purchase food. If any of your
outreach events include food, it must be paid for from other funds. Additionally, please note that
indirect charges will not be allowed under this agreement.
Subcontractor Name: Oran de Co6ntv `North Carolina
Amount Requested:
Budget Category A_ mount
Contractual
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Supplies
Equipment ::1500:00
Travel
Personnel
Fringe Benefits
Other itemize below 2250:00
TOTAL $4000.00
BUDGET:NARRATIVE:'
Supplies: Printer toner, mobile hotspot cards, paper, office supples.
Equipment: LCD projector, portable printer
Other:Advertisement(Senior Times x 3)
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;
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(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.
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2. Lobbying
Title 31 of the United States Code, Section 1352, entitled"Limitation on use of appropriated funds to
influence certain Federal contracting and financial transactions, generally prohibits recipients of Federal
grants and cooperative agreements from using Federal (appropriated)funds for lobbying the Executive or
Legislative Branches of the Federal Government in connection with a SPECIFIC grant or cooperative
agreement. Section 1352 also requires that each person who 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 making 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 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;
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(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.
—DocuSigned by:
� _,
Janice Tvler, De artment Direct
' or
Si tM??,3FMfhorized Certifying.Official:. Name and;Title;