HomeMy WebLinkAbout2018-032 Aging - TJCOG Title III fund agreementSERVICE A("' REEMENT
,rrrtxtt(-D REALT11 PROMOTION IMSEASIT, PREVENTION FUND
OF THE OLDER AMERICANS ACT
'['his agreement entered into as ofthis first day of,luly 2017 by and between the "I',riangle J
C.',ouncil of Governnients Area Agency on Aging (hereinafter referred to as "AAA") and
Orange ("ounty, a local political subdivision of the State o,f North Carolina, by and through
the Orange County Department on Aging (herein referred tea as the "Grantee").
WITNE,,SSETlJTIlAT:
Subject to the terms and conditions hereinafter set forth in this docurnen't, the AAA agrees to
grant Title 111-1) funds to the Grantee ['or the purpose which is described herein and
attached to this d0eUnient (Attachrrients A & 13).
NOW Tf IERLIT'ORE, in consideration of thew premises, and 111LItual covenants and
agreements hereinafter contained, the parties hereto agree as follows:
Scol)e of Services
The 43rantee agrees to USC the funds for Such allowable expenses and activities as outlined in
the approved service proposal, (Attachment A) Any material changes to the a proved
service proposal are subject to review and approval by the A.
Title 111-D funds must be used to provide and/or promote one or more Tier III Evidence!
Based Health Promotion Disease Prevention Programs, as approved by the Achriini stra 6 oil
fair' CommUllity Living and the NC Division of Aging and Adult services, A list of
approved prograrns is available at Littp,,',,,://www.ncoa.orL),/wi)-cojitent/Lipjo,,,Lci,,i/'Fitle-1111)-
li,ig rest_ -'"I'ici:,-Evideiiee-FINA L-72T MM?df
Current training and certification is reqUil-C(I to instruct or conduct the evidence-based
programs, if such training or certification is requirement of the evidence-based ProgranI.
Licensing agreements, fidelity monitoring or continuing education may be required t`or
select programs and these req UirCnic tits must be met, if applicable, 1.4inds may be used in
accordance with the service standards set forth by the NC Division of Aging and Adult
Set-vices for I lealth PromotionA)iscase Prevention, as amended 7/l/16.
Priorities for Service
'I"he Grantee agrees to prioritize the service needs of low income (including low-hicotne
minority elderly), rural elderly and elderly with limited English proficiency, as specified by
the Older Americans Act, as reauthorized 2016.
The Grantee agrees to abide by the ConsUiner Contribution Policy established by the NC
Divisioli ofAging and Adult Services,
at ConstiiiictC,oi�itributi,o�iis arse
— _ __
subject to inonthly reporting requiremerits in the Aging Reimbursement Management
System (ARMS).
'l" immure of Performance
Services are to corninctice on or after July 1, 2017 and shall be undertaken and purstied in
such sequence to assure completion on or before the end of the contract period, June 30,
201.8 of the state fiscal year
Conti-act Administration
The Administrator for the AAA shall be Mary K. Warren, Director, Triangle .1 Area Agency
on Aging. The Administrator for the Grantee shall be Janice Tyler
I Department Director. It is understood and agreed that the Administrator for the Grantee
shall, represent the Grantee in the perforriiance, of this Agreeinent. 'rhe Grantee shall notify
the AAA in writing if the Administrator changes during the grant period,
Availability of funds
'Fhe terms set forth in this Agreement for payment are contingent upon the receipt of
funding by the AAA.
Compensation and Method of Pa yment
The grant amount for'Fitle 111-1) is $5,965.00 + IOIYO local match ol'$663.00 foe as total
of S6,628.00.
'I I lie Grantee shall be conif)ensated for the work and services actually performed under this
contract by payments to be made monthly by the AAA, However, the total compensation
and reimbursement to be paid the Grantee under this contract shall not exceed the sure of
$5,965.00 in grant f"Unds, unless additional funds are authorized. The tennis set forth in this
agree rnent for payment are contingent upon receipt of grant, funds from the North Carolina
Division of Aging and Adult Services.
The Grantee will report, on a nionthly basis, and in the form specified by the AAA, the
allowable expenditures to be reimbursed' under this contract. The amount of allowable
expenditures reported will be reduced by the amount ol"prograin income (consunier
contributions) received for the service for the month reported,
Collection of Non-Federal Matching Resources
It is understood that the reqUirednon -rederal niatching resources will be secured by the
Grantee, The source of matching funds is as specified in Attachment A,
Monitoring and Inspections
This Agreement will be n:ionjt(.)red to assure that services are being provided as stated in the
Division ofAging and Adult Services (DAAS) monitoring Policies and Procedures at
)r�o.
qedures jnanUal
The nionitoring of'services provided under this Agreement shall be carried out by the AAA
in accordance with its Monitoring Plan, and as specified in DAAS Administrative Letter 12-
0.
Authorized representatives of tlie AAA and the North Carolina Division of Aging and Adult
Services may at any reasonable times review and inspect the prograrn activities and data
Collected pUrstjant to his contract. All reports and computations prepared by or for the
Cirantee shall 'be made available to authorized representatives of the AAA and the North
Carolina Division or Aging and Adult Services f(:)r inspection and review at any reasonable
times in the Grantee's of"fice, Approval and acceptance of'such material shall not relieve the
Grantee of its profe,ssional obligation to correct, at its expense, any en-OrS fOLInd.
To ensure adequate review and evaluation of the work and proper coordination arnong
interested parties, the AAA shall be kept [ally informed concerning the progress ofthe work
and services perflornned.
Grantee's Personnel
.rhe Grantee represents that it has, or will secure all personnel required to perform the
services provided for Under this contract. The Grantee shall be considered as an independent
contractor with responsibility for ni,aintaining liability and other relevant insurance
coverage, This agreement is not intended nor to be construed as an ernployer/employee
arrangement.
Accounting
The Grantee shall rnaintain complete accounting records sufficient to document receipts and
expenditures ol"grant funds under this agreement, All accounting records shOUld be
rnaintained in accordance with the North Carolina Local Government BUdget and Fiscal
Control Act,
Reporting
The Grantee agrees to maintain records and comply will, 911 reporting requirements of the
AAA and the NC Divisiori of Aging and Adult SCI-ViCCS, including but not Ifinited to
quarterly reporting of individuals served, providing copies of credentials of leaders and lay
leaders and a schedule of planned classes or activities, Select Evidence-Based Health
Promotion Disease Prevention programs may have reporting requirements outside of this
agreement.
Approval of Subcontract or Assignability
Any purchase of-'services with grant funds shall be carried out in accordance with the
procurenient and contracting policy of the Grantee, provided it does not conflict with
procurement and contracting requirements contained in 45 CFR, 92.36, (b)(I I).
The Grantee shall not assign all or any portion of its interest in this contract without prior
pen-nission from the AAA. Where Such assignment is executed, the contract between the
Grantee arid its sub-i-ecipient entity will specify the pass-through of funds and which
specific provisions of"this contract are, to be administered by the Grantee and the SUb-
recipient, Their st,ibcontract. will then become an addendUrn to the present, contract and the
Grantee will provide oversight of the sub-rc',cipicnt's performance, including, but 1101 limited
to, providing verification of sub-i-ecipient's eligibility for receipt of federal and state funding
and for appropriate service delivery, to the AAA,
Confidentiality and Security
[let- the requirerrients in I OA NCAC 415J and Section 6 of the Horne and Commurifty Care
Block Grarit policy and, l,)rocedures ManUal (updated 2016 through DAAS Administrative
Letter 16-11), client information in any format and whether recorded or not shall be kept
confidential arid not disclosed in a form that identi fics the person without the inf"ormcd
consent of the person or legal representative. Information n-tust be maintained in a secure
environnient with restricted access, and community set-vice providers must establish
procedures to prevent accidental disclosures froni data processing systems, The gnintee
must adhere to requirements liar protecting the security and confidentiality of client
inforniation.
Records Reten tion and Disposition
The Grantee is responsible for niaintaining custody of records and (locumentation to support
the allowable e; penditure of' funds, service provision, and the reimbursement for services,
The Grantee must adhere to the approved record retention and disposition schedule posted
semiannually on the website of the NC Department of lleaWi and Hurman Services (DHIIS)
C',ontroller at 1,Lttl?..://w�v w,iicdhIisLdoy/coI2,ti--o9/reteiitioii/j•eteiilioii,htiii.
The Grantee is not authorized to destroy records related to the provision of services, under
this Agreement except in cornpliance with theapirroved DfIHS retention and disposition
schedule, which allows for the proper destruction of records based on a schedule by funding
source and fiscal year, The agency agrees to comply with O NCAC 04M 0 10 when
deciding on as method of record destruction, Confidential records will be destroyed in such a
manner that the records cannot be practically read or reconstructed,
lndetnnity�•
The Grantee agrees to indeninify and save ha•inless the AAA, its agents, and employees
1'rorn and against and all loss, cost, damages, expenses, and liability arising out of
performance under this Agreement to the extent allowed by the state of North Carolina. 'Fhe
Grantee shall be considered as an independent contractor with responsibility for maintaining
liability and other relevant insurance coverage. This agreement is not intended nor to be
construed as an employer/employee arrangenient,
Audit/ Assessment Resolutions and Disallowed Costs
Federal fur)(IS May not be used to pay for a, Single or Yellow Book audit unless it a Federal
requirement. The federal single audit threshold is $750,0OO/State Funds shall not be used to
I'my flor a Single or Yellow Book audit if the Grantee receives less than $500,000 in state
funds, The Departnient oflicah:h and flunian Services will provide confirmation of federal
and state expenditures at the close of state fiscal year, lnformation On audit and Fiscal
reporting requirements can be found at
litt, ,/ /www.tie.gl°��:,�.t-,,ov/NCGrants/Ptib cRe LI
HcRe)ortsReaulation '
it is further understood that the Grantee is responsible to the AAA for- clarifying any audit
exceptions that niay arise frorn any assessment, agency single or financial audit, or audits
M
C011dUctcd by the State or Federal Governments. In the event the AAA or the North
Carolina Division of Aging and Adult Services disallows any expenditure of grant funds
made by (fie Grantee for any reason, the Grantee shall promptly reinaburse such funds to the
AAA. The AAA niay also withhold ffitUrC payrnentS under this or any other contract with
the Grantee Until the audit exceptions are cleared,
Changes
'The AAA may require changes in the work and services that the Grantee is to Perforrn
hereunder. Such changes which are InUtUally agreed upon by and between the AAA and the
Grantee, shall be incorporated in written ani end ments to this agreement, The Grantee may
request amendment of the agreement by notifying the AAA in writing, and if InUtUally
agreed Upon, these shall also be incorporated in written a mend rnen ts to this agreement.
Any reallocation of funding between grantee agencies shall be voluntary on the part of the
AAA and shall be effective only for the period of the agreement. "I'lie reallocation of funds
between grantee agencies will not affect the allocation of future funding tar the Girantee, If
during the pertbrinance period of [lie agreement, the AAA determines that as portion of this
funding will not be expended, the grant administrator for the Gyrantee shall be notified in
writing by the AAA in advance of any reallocation to other grantee agencies.
'Yertnination for Cause
If through any cause, the Grantee shall fail to fulfill in a timely and proper manner its
obligations under this Agreement, or the Grantee has or shall violate any of the covenants,
agreements, representations or stipulations ofthis Agreement, the AAA shall have the tight
to terminate this Agreement by giving the Grantee's Administrator written notice of such
termination no leaver than lifteen (15) days prior to the effective date of termination. In
such event, all finished and unfinished documents and other materials collected or prodUced
under this Agreement shall at the option of the Area Agency, beconic: its property, The
Girantee shall be entitled to receive just and eel dtable compensation for any work
satisfactorily perfi.)rMed Under this Agreement.
Notwithstanding the Ibregoing, the Grantee shall not be relieved of liability to the AAA for
daniages sustained by the AAA by virtue of any breach of this contract by the Grantee and
the AAA may withhold payment off" any additional Sums as security for payment of damages
caused by the Grantee's breach, until such tirne as the exact amount ofthe darnages
resulting from such breach is determined.
Termination for (,onvenience
The AAA may ternihiate this agreement 6car convenience at any tirneby giving written
notice to the Grantee of such ternaination. and specifying the date thereof, no fewer than
fifteen (1 5) days prior to the effective date of such termination, In that event, all finished or
unfinished documents and other materials produced or collected shall, at the option of the
AAA, become the property of the AAA.
I
The Grantee shall be paid the grant reimbursement percentage of the actual allowable
expenses that have been incurred by the Grantee prior to the effective date of such
lermination, less payrnents, Of conipensation previously made by the AAA.
Rights in Docutnents, Materials and Data Produced
The Grantee agrees that at the discretion of the AAA, all reports and other data prepared by
or 11)r it under the terms of this contract shall be delivered to, become and remain, tile
property of the AAA LIP011 WrIllillatiOn Or COMpletiOn Of the work, Both the AAA and the
Grantee shall have the right to use same without restriction or limitation and without
compensation to the other, For the purposes of this contract, "data" inClUdes sound
recordings, or other graphic representations, and works of similar nature, No reports or
other d0CUlIICnts produced in whole or in part under this contract shall be the subJect ()fail
application for copyright by or on behall'of the ("irantee,
Interest of the Grantee
'File Grantee covenants that neither. the Grantee or its agents or employees presently has all
interest, rior shall acquire an interest, direct or indirect, which coilflicts in any planner or
degree with the perlorniance of its service hereunder, or which would prevent, or tend to
pi-event, the satisfactory performance of the Cirantee's service hereunder in an impartial and
unbiased inanner. The Cirantee further covenants that in the performance of this contract no
person having, any such interest shall be employed by the Grantee as an agent, subcontractor
or otherwise.
Interest of Members of the Area Agency and Others
No officer, member Or employee of the AAA, and no public official ofany local, state or
federal government that is aiTected, in any way by the performance ofthis work, who
exercises any function or responsibilities in the review or approval ofthe work ear any
component part thereof,, shall participate in any decisions relating to this contract which may
affect his personal interest or file interest of any corporation, Partnership or association ill
which fie is, directly or indirectly, interested; nor sliall any such perscm have any interest,
direct or indirect, in this contract or the proceeds arising therefrom,
Disputes and Appeals
Any dispute concerning a question of fact arising under this agreement shall be identified to
the designated grants adn'tinistrator for the AAA, In accordance with Lead Regional
Organization (LRO) policy, as written decision shall be promptly furnished to the designated
grants adiilinistrator for the Grantee,
The decision ofthe LRO is final unless within twenty (20) days of receipt of such decision
the Grantee furnishes a written requestft')r appeal to the Director of the North Carolhia
Division of Aging and Adult Services, with a copy sent to the AAA. The request for appeal
shall state the exact nature of the complaint. The Division of Aging and Adult SerACCS Will
inform the Grantee ofits, appeals procedures and will inform the AAA that an appea l. has
been filed, Procedures thereafter will be determined by the appeals, process of the Division
of'Aging and AdUlt Services. '-I'hc: state agency address is as follows:
I
1) irector
North Carolina Division of in and Adult Services
dill Mail Service Center
693 Pali-net, Drive
Raleigh, North Carolina 27699-2101
Applicable Law
This contract is executeci and is to be performed in the State of North Carolina, and all
questions of interpretation and constructiori shall be COD stray ed by the la ws of such State.
By exectition of this Agreement the Parties certify that they have not been ideritified nor
utilized the services, or any agent, or sari contractor on the list created by the N(III State
"rreaSUrer pUrsuant to G. S. 147-86.58. By signature, each party agrees to the terms
containe(I herein and each ffirther certifies that SLrCII terms clo not represent a conflict of
interest.
G'rantee: Orange ("OL111ty.
By:
i3/onllie
'I 'riangle J COLHICil of Govertiments/Area Agency on Aging
By:
A, c sley
ectitive Director, 'ITiara ,gleJ(".otincilofGovei-ni�i-iejits
Provision for payinerit eat` the monies to fall dUe Under this Agreement within the current
fiscal year have been inade, by appropriation duly aUthorized as required by the Local
Government Budget arid Fiscal Control Act.
By:
A. WeJL4, FIriance bireetor, Triangle J Council of(loverninents
VA
Attachment A: Budget and Sew-vice Plan
l "itl 111-D Allocation
Services* Arthritis Foundation Exercise Program
, I , ai Chi for Arthritis/Falls Prevention
Walk with T^ ease
Living Healthy with Chronic Conditions (CDSME1)
— — - -------- - - - — — — _-- - _____ - -- - - __ . . . . . . .........................................................
Budget Toad $6,628 for Instructors for F11411P classes, inc I uding training for atiy iiew
instructors,
. . ........ . .......... ........ ...
Matching Funds Orange "ounty ftinds
Source
*It is fhe responsihffi�y (?f the Grwvee to obtain aqv mquired ficensure, hutructor,
training, and'Aielit)" f1lonitoritq,", as qp1')IiwbIe' to setvicay pro vided A4011PYfiv oversight undlorfidefity
checks rnqy be required situational4y,
Methodology to Address Set-vice Needs Of LOW 111COITIC (InClUding Low Income Minority
Elderly, Rural Elderly and Elderly with 1,Jrnited English Proficiency:
Our target audience consists of resident's age 50+ who
live, work and/ r utilize Orange County senior set-vices,
We plan to reach out to Senior Center participants,
members of faith-based organizations (150+),
department newsletter (14,000+), s,ubscribers, e-
newsletter (2,500+) subscribers and seniors who attend
the nUmerous health fairs we participate jr). We also plan
to prominently highlight all e,vidence -bas ed classes in our
department newsletter,
M
Attachment B:
The undersigned states, that,
ester -al Ceftifications
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: Nondjscrirninaticln;
lo, The Certification, Regarding, Drug -Free Workplace Requirements;
c, The Certification: Regarding Environimentall Tobacco Smoke;
d, The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tiler Covered Transactions, and
el, The Certification, Regarding Lobbying;
3. He or she has comiplleted the Certification Regarding Drug-Free Workplace Requirements by
pirovidingi the addresses at which the contract work will be performed;
4. [Check the applicable statement]I
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 Ilobbyiing entity for
influencing or attempting to influence an officer or employee of an agency, a Mernber of
Congress, an officer or employee of Congress, or an employee of a, Member of Congress in
connection with a covered Federal action;
RM
[X ]HIe or she has not completed the attached Discl'osuire 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.
X�I
Signature
(Mjrjgg_(',QUntY De - artm tit on
Gratitee Name
6t'YPA'I
Tifle
Date
I
1. Certification Regarding Nondiscrimination
Tbe 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.1- 88-3,52) which prohibits discrimination on, the basis of race, color or national
origin; (b) Title IX ofthe 1.1,'ducation Amendments of' 1972, as amended (20 US.0 16 1-
1683, and 1685-1686), which prohibits discrimination on the basis of sex., (c) Section 504 of
the Rchabilitation Act of 1973, as anlended (29 U §794), which prohibits
discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as
amended (42 (J.&C 6101-610�7), which prohibits, discrimination on the basis of age�,
, (e)
the Drug Abuse Office an(] Treatment Act of 1972 (PJI- 9,2-255), as amended, relating to
nondiscrimination on the basis of drLIg abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, 'fi-eatment and Rehabilitation Act of 1970 (P.L. 91-6,16), as
amended, relating to nondiscrimination on the basis ol'alcohol abuse or alcoholism; (g)'I'itle
Vill of the Civil Rights Act of 1968, (42 1.1. ,E" §3601 et seq), as amended, relating to
nondiscrimi nation in the sale, rental or linaricing of housing; (h) the Food Stamp Act and
[JSDA policy, which prohibit, discrimination on the basis of religion and political befiel's;
and (i) the requirements of any other nondiscrimination statutes which rmay apply to this
Agreenient.
It. Certification Regarding Drug-Free Workplace Requirements
1 . The Contractor certifies, that it wifli 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 ol"such prohibitio�n;
b. F,',stablishing a drug-free awareness prograrn to int"orm ernployees about:
i. The dangers of drug abuse in the workplace;
ii. 'rhe Contractors policy of maintaining a, drug -free workplace;
iii. Any ai7ailable 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 perfornlance of the
agreer-nera be given a copy of the statement required by paragraph (a),
d. Notifying the erriployee in the staternent required by paragraph (4) that, as a
condition of ernploymentt'inder the agreenient, the employee Nvill:
i, Abide by the ternis ofthe staterrient; and
ii, Notify the employer of any criminal draw g statute conviction for a violation
Occurring in the workplace no later than rive 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;
11. Taking one of the tbIlowing 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 SLICII 1XII•POSeS by as F'cdera,l, State, or local
health, law enforcement, or other appropriate agency; and
g. Making a good faith effort to continue to rnaintain a drug-five workplace through
iniplernentation of paragraphs (a), (b), (c), (d), (e), and (1).
3, Contractor will inform the Department of any additional sites for perforalancie of work
under this agrecilient.
4 1"alse certification or violation of the certification may be grounds for suspension of
payment, suspension or termination of grants, or government -wide Federal SUSpellSiOn Or
debarMent. 45 CER, 82,510,
Ill. Certification Regarding Environmental Tobacco Smoke
Public Law 103 -227, Part (',-,Environmental Tobacco Smoke, a1so known as the Pro-
not be permitted in any portion of any
C,hifdreii Act ol '1994 (Act), requires that sinoking
indoor facility owned or ]eased or contracted for by an entity and, used routinely or regularly
for the provision of` health, day care, cdUiCati011, or library services to children under the age
of 18, iftlie services are funded by kale ral programs either directly or 0-trough State or local
governments, by 1 'cderal grant, contract, loan, or loan guarantee, The taw does not apl.-)Iy to
children's services provided in private residences, facilities funded solely by Medicare or
Medicaid Furids, and podions of Cacifities used for inpatient drug or alcohol treatilient.
1,,'ailure tar comply with the provisions of tile law rnay result in the imposition of a civil
monetary penalty of tip to $1,000.00, per day and/or the imposition of an adn'dilistrative
compliance order on the responsible entity.
The Contractor certifies that it will comply with the •eqUirenlents of the Act, The
Contractor further agrees that it will require the language of this certification be included in
any subawards that contain provisions lbr children's services and that, all SUbgrantees shall
certify accordingly.
IV. Certification Regarding Debarment, Suspens,ion, Ineligibility and Vol,untary
Exclusion Lower Tiei-
Covered, Transactions
Instructions
1"The phrase "prospective lower tier participant" means, the Contractor.]
t. By Sigl'IiDg and submitting this docurnent, the prospective lower tier participant is
providing the certification set out below,
2. 1 'he certification in this clause is a material representatio'n of the I-lict 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 er•oncous certification, in
addition to other remedies available to the Federal Government, the departmer)t or
agency with which this transaction, originate may pursue available remedies, including
suspension and/or debarnient.
3. The prospective lower tier participant will provide ininiediate written notice to the
person to whom. this proposal is submitted if at any time tile prospective lower tier
participant learns that its certification was erroncous when subirritted or has become
erronCOLIs by reason of changed Circumstances.
4, The terms, "covered transaction," "debarred," "suspended," "ineligible," "lower tier
covered transaction," "participant," "'person,"' "'primary covered transaction," "principal. r "
"proposal," and "voluntarily excluded," as used in this clause, have the meanings Set OLA
in the Definitions and Coverage sections of rules iniplernenting ExeCUtiVe Order 12549,
45 C 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 subrnitting 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 subrnitting this document that it
Will include the c1aUSC titled " Cerd fi cation Regarding Debarmcnt, Suspension,
Ineligibility and Voluntary Exclusion—Lower Tier Covered Transaction," without
tnodification, in all lower tier covered transactions and in all solicitations for lower tier
covered transactions.
UN
7. A participant in a covered transaction may rely upon as certification , of a prospective
participant in as 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 inay decide the method and frequency by which
it detennines the eligibility of its principals. EL-ich participant iiiay, but is not reqUircd to,
cheek the Nonp•ocurernent List,
8. Nothing contained in the foregoing shall be construed to require establishment of a
system, ofrecords in order ter render in good faith the certification required by this ClaUSC,
The knowledge and information of as participant is not required to exceed that which is
normally possessed by a prudejit person in the ordinary course of 'business dealings.
9 l-'Acept for trailisactions authorized in paragraph 5 of these instrUctions, if a participant in
a covered transaction knowingly enters into as lower tier covered transaction with a
person who is suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other •en'iedies, 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 VOILuItUrily 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 (lie 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:
No l"ederal appropriated funds have been paid or will be paid by or on behalf of the
Undersigned, to any person for inflUCIIChIg or attempting to illflUnce an officer or
eniployce of any agency, a Member of Congress, aan officer or eiriployce of Congress, or
an ernployee of a Member of Congress in connection with the awarding of any Federal
contract, continUati0a, renewal, amendment, or modification of any Federal coi,itract,
grant, loan, or cooperative agreement.
2. 11 'any ffinds 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, as
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
13
agreement, the undersigned shall complete and submit Standard Form SF-LLL,
"DiSCIOSUre off,obbying, Activities," in accordance with its instructions,
I 'The Undersigned shall require that the language of this certification be included in the
award document for subawards at all tiers (il'],ClUding subcontracts, SUbgrants, and
contracts under grants, loans, and cooperative agreements) who receive federal funds of
$ 100,000.00 or more and that all SLIbrecipients shall certify and disclose accordingly.
4, This, certification is a material representation Of ftICt Upon which reliance was placed
when this transaction was made or entered into, Submission of this certification is a
prereqLlkitC R)r inaking Or entering into this transaction imposed by Section 1352, '111le
31, 111,5, 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 Im, each such
I'ailUre.
V1. Disclosure Of Lobbying Activities
Instructions
']'his disclosure forni shall be completed by the reporting entity, whether subawardee or
prime I ederal recipient, at the initiation or receipt of a covered Federal action, or a material
Change to 8, Previous filing, pursuant to title 31 U. ,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 Mcniber of
Congress, all officer Or employee of Congress, or an employee of a Member of Congress in
connection with a covered Federal action. Use the SF-LIA..-A Continuation Shect for
additional in,formiation if the space on the form is inadequate. Complete all items that al)]-.)Iy
for both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Managenlent and Budget for additional inforination.
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.
1
2. Identify tile status cif" the covered Y ederal action.
3. Identify the appropriate classitication of' this report, '11' this is a Billow -up report caused
by as material change to the infornialion previously reported, enter the year and quarter in
which the change oecurred. Enter the date ofthe 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 classiflication of the reporting
entity that designates if it is, or expects to be, a prinic, or sub-award recipient. Identify
the tier of" the subawardee, e.g,, the first subawardee of the prime is the Ist tier.
14
Subawards include but are not limited to subcontracts, SUbgrants and coritract, awards
under grants.
5e fl" the organization filing the report in Item 4 checks "Subawardec", then enter the flill
narne, address, city, state and zip code of the prime Fcdcral recipient. IncItIde
(,",ongressional District, if known.
6 11'nter the narne of the Federal agency making, the award or loan corninitment. Include at
least one organizational level below agency naine, if' known. For exaniple, Department
of Transportation, United States Coast Guard.
T Enter the Federal program narne or description for the covered Federal action (Item 1),
If known, enter the full Catalog of Federal Dorriestic, Assistance ((TDA) nuniber for
grants, cooperative a-green-terits, loans, and loan conimitments.
8, Enter the most appropriate 1ederal Identifying number availatflc for the Federal action
identified in Itern I (c,g., Request for Proposal (RFP) nurnber, Invitation for Bid (I B)
number, grant announcement number, the contract grant, or loan award num-ber, the
application/proposal control number assigned by the Federal agency), fnclude prefixes,
e.g�, "RIT-DE-90-001."
9. For a covered Federal action where there has been an award or loan cornmitnient by the
Federal agency, enter the Federal amount of the award/loan commitirient for the prime
entity identified in Item 4 or 5,
10. (a) Enter the ftill narne, address, city, state and zip code of' the lobbying entity engaged
by the reporting entity identified in Item 4 to influence the covered 1"ederal action.
(b) Friter the Rill names of the: individual(s) performing services, and include full address if'
different from I O(a). l,mer 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 ma 'e (planned), Cheek all boxes that apply. If this is
as material change report, enter file CUMUlative amount of payment made or planned to be
made,
12, Check the appropriate boxes. Check all boxes, that apply, If paymem is niade through
,in in I
- �ind contribution, specify the nature and valUe of the in-kind payment.
13,, (",heck the appropriate boxes,. Check all boxes that apply, If other, specify nature.
14. Provide as specific and detailed description of the services that the lobbyist has
performed, or will be expected to perrorm, and the date(s) of any services rendered.
111CIUde all preparatory and related activity, not just tirne spent in actual contact with
M
Federal officials. Identify the Federal official(s) or employee(s) contacted or the
officer,(s), employee(s), or Member(s) ol'C,ongress that were contacted.
'15. Check whether or not a F -1_ LL- Coni inUation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his/her name, title, and
telephone number.
16
Disclosure Of Lobbying Activities
(Approved by OMB 0344-0046)
C�ompiete this form to disclose lobbying activities pursuant to 31 U, S.C. 1; 352
m
Typ of Aci�om 2 S,„aw5 cl Federal A(,.m, 3, Report Type�
a, c o n t E,s c I
a �nv!iat filing
C' g!3"t
b nrater'l Wl'arl'�3'e
:00perat"ve agfeimem Post-P iard
so 3 r,
For Material Change Only.,
Date Of Last Report
4,
Name and Add,i'bs of Rep-- riing Enoty,
If Repoft,rg Ent�lq in No, 4 �s 5-nw Name
and Ad,4°ess of Prirr,=
Congressional
Dis� Kmv
Congreas'lonal Distrio, V knoon,k
F ,,
Fedefal
7 Federal Prc,; raq) Narre,'Cewirrion
CFCA Nnibet f,,i ap,,6,�iblc)
A,:tk:7iw,,T)Eef 0I 0ownli
Aveard Amou ��� (0 kr'oym)
10
a 14arre and 7-64,jrj�s oti Loftpq Ent4ty
b, rndiv,J,�� ��s Performmg Sewces Nmcfvdmq, addieo d
((if injw,'dua?, aj ! nime, name
10,5 m3me, Arsf name
I
Arr,�;,,,mof Pay I meni t,�heck 0 rhv oppfly
I Type of Paymem frhe.* aUlhat aprill,,,
actual plmme-1
a, wainer
One-time fee
heck, a# ,97TT—
o
fj C (missio n
1, :ont,ngir,.i fee
3, a 5 h
a deferred
b speo+f Natre
p. C oihw, spe,.ity�
V3�"e
Brief cesr"' ;ljon CT or
hfzmber(s� o:nmoed, frr Payment ind):ats,e in [,,em I
cormuat'r'n SF-LLL-A amached,
NO;
LIVlo, gh th S formm iS JWr-.rzed by
S gnaiure�
t,,Je r U C, 5seti,7m I a52 Thqs di,,dostiTe of Iobbym;
acliv bps is a qjar:r';� reresentat"':'r of faRn upon which
Py'nl Name�
tehanci w35 ty the gier cabove a,thcm tN5 vansaction
was made or enWeo into, T!�,s c s6 Buie l5 re;Ofet
'rrt',e;
pvrsj.jrj to 'If U S, C, 1362 This info nma zk n wi16 be
reporic,d to t,e Cc mm.-s5 semi zmmjalty and "M be
Telephone No. Date:
ava ' ' 3�1,e pulAic Prspeten- Any pees -�,A w' ;a f�4i�s to Me
tl,e requifed 5c,• :*use shaW ti sLt� P:t to a riv l pvtlalty of
not le, ss aian ! IC,000 ;n,:4 not mo4e tf 3n S T00,C-O.) for eaoh
S"xh raflure,
Federal Use Only
A,�thodzsd for Looa�
Standard Form - LLL
m