HomeMy WebLinkAbout2018-782 Aging - TJCOG COG Title 3-D Health promotion grant SERVICE AGREEMENT
TITLE III- D HEALTH PROMOTION DISEASE PREVENTION FUND
OF THE OLDER AMERICANS ACT
This agreement entered into as of this first day of July 2018 by and between the Triangle
J Council of Govenunents Area Agency on Aging (hereinafter referred to as " AAA") and
Orange County , a local political subdivision of the State of North Carolina, by and through
the Orange County Department on Aging (herein referred to as the " Grantee") .
WITNESSETH THAT :
Subject to the terms and conditions hereinafter set forth in this document , the AAA agrees to
grant Title III - D Funds to the Grantee for the purpose which is described herein and
attached to this document (Attachment A) ,
NOW THEREFORE , in consideration of the premises , and mutual covenants and
agreements hereinafter contained , the parties hereto agree as follows :
Scope of Services
The Grantee agrees to use the funds for such allowable expenses and activities as outlined in
the approved service proposal document . Any material changes to the approved service
proposal are subject to review and approval by the AAA .
Title III- 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 Administration
for Community Living and the NC Division of Aging and Adult services . A list of
approved programs is available at https : //www . ncoa . org/wp - conteiit/uploads/Title - IIID -
Highest- Tier-Evidence -FINAL - 7 . 27 . 16 . pdf.
Current training and certification is required to instruct or conduct the evidence -based
programs , if such training or certification is a requirement of the evidence - based program .
Licensing agreements , fidelity monitoring or continuing education may be required for
select programs and these requirements must be met, if applicable . Funds may be used in
accordance with the service standards set forth by the NC Division of Aging and Adult
Services for Health Promotion/Disease Prevention , as amended 7/ 1 / 16 .
Priorities for Service
The Grantee agrees to prioritize the service needs of low income (including low- income
minority elderly) , rural elderly and elderly with limited English proficiency, as specified by
the Older Americans Act , as reauthorized 2016 .
Consumer Contributions
The Grantee agrees to abide by the Consumer Contribution Policy established by the NC
Division of Aging and Adult Services ,
http : //N"vw . nedhlis . gov/aging/consumercontributions . htm . Consumer Contributions are
subject to monthly reporting requirements in the Aging Reimbursement Management
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System (ARMS ) .
Time of Performance
Services are to commence on or after July 1 , 2018 and shall be undertaken and pursued in
such sequence to assure completion on or before the end of the contract period , June 30 ,
2019 of the state fiscal year .
Contract Administration
The Administrator for the AAA shall be Mary K . Warren , Director, Triangle J Area Agency
on Aging . The Administrator for the Grantee shall be Janice Tyler, Department on Aging
Director . It is understood and agreed that the Administrator for the Grantee shall represent
the Grantee in the performance of this Agreement . The Grantee shall notify the AAA in
writing if the Administrator changes during the grant period .
Availability of Funds
The terms set forth in this Agreement for payment are contingent upon the receipt of
funding by the AAA .
Compensation and Method of Payment
The grant amount for Title III-D is $ 8 , 669 . 00 + 10 % local match of $ 963 . 00 for a total
of $ 9 , 633 . 00 .
The Grantee shall be compensated 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 sum of
$ 8 , 669 . 00 in grant funds , unless additional funds are authorized . The terms set forth in this
agreement 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 monthly 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 of program income ( consumer
contributions ) received for the service for the month reported .
Collection of Non -Federal Matching Resources
It is understood that the required non-federal matching 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 monitored to assure that services are being provided as stated in the
Division of Aging and Adult Services (DAAS ) monitoring Policies and Procedures at
http : //www , ncdl hs . gov/document/section- 308 - aaa-policies - and-procedures -manual .
provided under this Agreement shall be carried out by the AAA
The monitoring of services
in accordance with its Monitoring Plan , and as specified in DAAS Administrative Letter 12 -
08 .
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Authorized representatives of the AAA and the North Carolina Division of Aging and Adult
Services may at any reasonable times review and inspect the program activities and data
collected pursuant to his contract . All reports and computations prepared by or for the
Grantee shall be made available to authorized representatives of the AAA and the North
Carolina Division of Aging and Adult Services for inspection. and review at any reasonable
times in the Grantee ' s office . Approval and acceptance of such material shall not relieve the
Grantee of its professional obligation to correct, at its expense , any errors found .
To ensure adequate review and evaluation of the work and proper coordination among
interested parties , the AAA shall be kept fully - informed concerning the progress of the work
and services performed .
Grantee ' s Personnel
The 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 maintaining liability and other relevant insurance
coverage . This agreement is not intended nor to be construed as an employer/ employee
arrangement .
Accounting
The Grantee shall maintain complete accounting records sufficient to document receipts and
expenditures of grant funds under this agreement . All accounting records should be
maintained in accordance with the North Carolina Local Government Budget and Fiscal
Control Act .
Reporting
The Grantee agrees to maintain records and comply with all reporting requirements of the
AAA and the NC Division of Aging and Adult Services , including but not limited 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
Contracts funded with federal grants must be procured in a manner that conforms with all
applicable federal laws , policies and standards as well as state law and local policies
including those under the OMB Uniform guidance (2 C . F . R . part 200) .
The Grantee shall not assign all or any portion of its interest in this contract without prior
permission from the AAA . When such assignment is executed , the contract between the
Grantee and its sub -recipient entity will specify the passAhrough of funds and which
specific provisions of this contract are to be administered by the Grantee and the sub -
recipient . Their subcontract will then become an addendum to the present contract and the
Grantee will provide oversight of the sub -recipient ' s performance , including, but not limited
to , providing verification of sub -recipient ' s eligibility for receipt of federal and state funding
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and for appropriate service delivery , to the AAA .
Confidentiality and Security
Per the requirements in l0A NCAC 05J and Section 6 of the Home and Community Care
Block Grant Policy and Procedures Manual (updated 2016 through DAAS Administrative
Letter 16 - 11 ) , client information in any format and whether recorded or not shall be kept
confidential and not disclosed in a form that identifies the person without the informed
consent of the person or legal representative . Information must be maintained in a secure
environment with restricted access , and community service providers must establish
procedures to prevent accidental disclosures from data processing systems . The grantee
must adhere to requirements for protecting the security and confidentiality of client
information .
Records Retention and Disposition
The Grantee is responsible for maintaining custody of records and documentation to support
the allowable expenditure 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 Health and Human Services ( DHHS )
Controller at http : //www . ncdlihs . gov/ control /retenti. ori/retention , htin9
The Grantee is not authorized to destroy records related to the provision of services under
this Agreement except in compliance with the approved DHHS 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 07 NCAC 04M . 0510 when
deciding on a method of record destruction . Confidential records will be destroyed in such a
manner that the records cannot be practically read or reconstructed .
Indemnity
The Grantee agrees to indemnify and save harmless the AAA , its agents , and employees
from and against and all loss , cost , damages , expenses , and liability arising out of
performance under this Agreement to the extent allowed by the state of North Carolina , The
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 arrangement .
Audit/ Assessment Resolutions and Disallowed Costs
Federal funds 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 , 000/ State funds shall not be used to
pay for a Single or Yellow Book audit if the Grantee receives less than $ 500 , 000 in state
funds . The Department of Health and Human Services will provide confirmation of federal
and state expenditures at the close of the state fiscal year . Information on audit and fiscal
reporting requirements can be found at
https : //www . netreasurer . com/slg/Ifni/audit acct/single audit/compliance supplements/Page
s/default . aspx .
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It is further understood that the Grantee is responsible to the AAA for clarifying any audit
exceptions that may arise from any assessment , agency single or financial audit, or audits
conducted 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 the Grantee for any reason, the Grantee shall promptly reimburse such funds to the
AAA . The AAA may also withhold future payments 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 perform
hereunder . Such changes which are mutually agreed upon by and between the AAA and the
Grantee , shall be incorporated in written amendments to this agreement . The Grantee may
request amendment of the agreement by notifying the AAA in writing , and if mutually
agreed upon , these shall also be incorporated in written amendments 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 . The reallocation of funds
between grantee agencies will not affect the allocation of future funding to the Grantee . If
during the performance period of the agreement , the AAA determines that a portion of this
funding will not be expended , the grant administrator for the Grantee shall be notified in
writing by the AAA in advance of any reallocation to other grantee agencies .
Termination 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 of this Agreement, the AAA shall have the right
to terminate this Agreement by giving the Grantee ' s Administrator written notice of such
termination no fewer than fifteen ( 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, become its property . The
Grantee shall be entitled to receive .just and equitable compensation for any work
satisfactorily performed under this Agreement .
Notwithstanding the foregoing , the Grantee shall not be relieved of liability to the AAA for
damages sustained by the AAA by virtue of any breach of this contract by the Grantee and
the AAA may withhold payment of any additional sums as security for payment of damages
caused by the Grantee ' s breach, until such time as the exact amount of the damages
resulting from such breach is determined .
Termination for Convenience
The AAA may terminate this agreement for convenience at any time by giving written
notice to the Grantee of such termination and specifying the date thereof, no fewer than
fifteen ( 15 ) days prior to the effective date of such termination . In that event , all finished or
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unfinished documents and other materials produced or collected shall , at the option of the
AAA , become the property of the AAA .
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
termination , less payments of compensation previously made by the AAA .
Rights in Documents , Materials and Data Produced
The Grantee agrees that at the discretion of the AAA , all reports and other data prepared by
or for it under the terms of this contract shall be delivered to , become and remain , the
property of the AAA upon termination 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 documents produced in whole or in part under this contract shall be the subject of an
application for copyright by or on behalf of the Grantee .
Procurement
Contracts and purchases funded with federal grants must be procured in a manner that
conforms with all applicable federals , policies and standards as well as state law and local
policies , including those under the OMB Uniform Guidance (2 C . F . R . part 200 ) .
Interest of the Grantee
The Grantee covenants that neither the Grantee nor its agents or employees presently has an
interest, nor shall acquire an interest, direct or indirect, which conflicts in any manner or
degree with the performance of its service hereunder, or which would prevent, or tend to
prevent, the satisfactory performance of the Grantee ' s service hereunder in an impartial and
unbiased manner . The Grantee 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 of any local , state or
federal government that is affected in any way by the performance of this work , who
exercises any function or responsibilities in the review or approval of the work or any
component part thereof, shall participate in any decisions relating to this contract which may
affect his personal interest or the interest of any corporation, partnership or association in
which he is , directly or indirectly , interested ; nor shall any such person 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 administrator for the AAA . In accordance with Lead Regional
Organization (LRO ) policy , a written decision shall be promptly furnished to the designated
grants administrator for the Grantee .
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The decision of the LRO is final unless within twenty (20) days of receipt of such decision
the Grantee furnishes a written request for appeal to the Director of the North Carolina
Division of Aging and Adult Services , with a copy sent to the AAA . The request for appeal
shall state the exact nature of the complaint . The Division of Aging and Adult Services will
inform the Grantee of its appeals procedures and will inform the AAA that an appeal has
been filed . Procedures thereafter will be determined by the appeals process of the Division
of Aging and Adult Services . The state agency address is as follows :
Director
North Carolina Division of Aging and Adult Services
2101 Mail Service Center
693 Palmer Drive
Raleigh , North Carolina 27699 - 2101
Applicable Law
This contract is executed and is to be performed in the State of North Carolina, and all
questions of interpretation and construction shall be construed by the laws of such State .
By execution of this Agreement the Parties certify that they have not been identified nor
utilized the services or any agent or subcontractor on the list created by the NC State
Treasurer pursuant to NCGS 147 - 86 . 55 - 69 . By signature , each party agrees to the terms
contained herein and each further certifies that such terms do not represent a conflict of
interest .
Grantee : Orange County Department on Aging
By :
Name, Title
Triangle J Council of Governments/Area Agency on Aging
or
By :
_ Lee Worsley
%- Executive Director, Triangle J Council of Governments
44�Provision for payment of the monies to fall due under this Agreement within the current
fiscal year have been made by appropriation duly authorized as required by the Local
Government Budget and Fiscal Control Act .
By :
Judy A . ler, Finance Director, Triangle J Council of Governments
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Attachment A . Approved Service Plan
Title III- D Allocation
Services *
Tai Chi for Arthritis
Chronic Disease Self- Management Education Program ( CDSMP
Arthritis Foundation Exercise Program (AFEP )
*It is the responsibility of the Grantee to obtain any required licensure, certification/recertification, instructor
training, and fidelity monitoring, as applicable to services provided. MO Us for oversight and/or fidelity
checks may be required situationally.
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Attachment 13 : Federal Certifications
The undersigned states that :
1 . He or she is the duly authorized representative of the Contractor named below ;
2 . He or she is authorized to make , and does hereby make , the following certifications on behalf of
the Contractor , as set out herein :
a . The Certification Regarding Nondiscrimination ;
b . The Certification Regarding Drug - Free Workplace Requirements ;
c . The Certification Regarding Environmental Tobacco Smoke ;
d . The Certification Regarding Debarment , Suspension , Ineligibility and Voluntary Exclusion
Lower Tier Covered Transactions ; and
e . The Certification Regarding Lobbying ;
3 . He or she has completed the Certification Regarding Drug - Free Workplace Requirements by
providing the addresses at which the contract work will be performed ;
4 . [;Check the applicable statement]
[ ] He or she has completed the attached Disclosure Of Lobbying Activities because the
Contractor has made , or has an agreement to make , a payment to a lobbying entity for
influencing or attempting to influence an officer or employee of an agency , a Member of
Congress , an officer or employee of Congress , or an employee of a Member of Congress in
connection with a covered Federal action ;
OR
[ X ] He or she has not completed the attached Disclosure Of Lobbying Activities because
the Contractor has not made , and has no agreement to make , any payment to any
lobbying entity for influencing or attempting to influence any officer or employee of any
agency , any Member of Congress , any officer or employee of Congress , or any employee of
a Member of Congress in connection with a covered Federal action .
5 . The Contractor shall require its subcontractors , if any , to make the same certifications and
disclosure .
.sC Department Director
igature Title
Orange County Department on Aging December 3 , 2018
Grantee Name Date
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I . Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to
nondiscrimination . These include but are not limited to : (a) Title VI of the Civil Rights Act
of 1964 (P . L . 88 - 352 ) which prohibits discrimination on the basis of race , color or national
origin ; (b ) Title IX of the Education Amendments of 1972 , as amended (20 U . S . C . § § 1681 -
1683 , and 1685 - 1686 ) , which prohibits discrimination on the basis of sex ; (c ) Section 504 of
the Rehabilitation Act of 1973 , as amended (29 U . S . C . § 794 ) , which prohibits
discrimination on the basis of handicaps ; ( d) the Age Discrimination Act of 1975 , as
amended (42 U . S . C . § § 6101 - 6107 ) , which prohibits discrimination on the basis of age ; ( e)
the Drug Abuse Office and Treatment Act of 1972 (P . L . 92 -255 ) , as amended , relating to
nondiscrimination on the basis of drug abuse ; ( f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention , Treatment and Rehabilitation Act of 1970 ( P . L . 91 - 616 ) , as
amended , relating to nondiscrimination on the basis of alcohol abuse or alcoholism ; ( g) Title
VIII of the Civil Rights Act of 1968 (42 U . S . C . § § 3601 et seq . ) , as amended , relating to
nondiscrimination in the sale , rental or financing of housing ; (h) the Food Stamp Act and
USDA policy , which prohibit discrimination on the basis of religion and political beliefs ;
and (1 ) the requirements of any other nondiscrimination statutes which may apply to this
Agreement .
II . Certification Regarding Drug-Free Workplace Requirements
1 . The Contractor certifies that it will provide a drug -free workplace by :
a. Publishing a statement notifying employees that the unlawful manufacture ,
distribution, dispensing, possession or use of a controlled substance is prohibited in
the Contractor ' s workplace and specifying the actions that will be taken against
employees for violation of such prohibition ,
b . Establishing a drug- free awareness program to inform employees about :
i . The dangers of drug abuse in the workplace ;
lip The Contractor ' s policy of maintaining a drug4ree workplace ;
iii . Any available drug counseling , rehabilitation , and employee assistance
programs ; and
iv . The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace ;
c . Making it a requirement that each employee be engaged in the performance of the
agreement be given a copy of the statement required by paragraph (a) ;
d . Notifying the employee in the statement required by paragraph ( a) that, as a
condition of employment under the agreement, the employee will :
i . Abide by the terms of the statement ; and
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ii . Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five days after such conviction ;
e . Notifying the Department within ten days after receiving notice under subparagraph
(d) ( ii ) frorn an employee or otherwise receiving actual notice of such conviction ;
f. Taking one of the following actions , within 3 0 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
to
11 . Requiring such employee to participate satisfactorily in a drug abuse assistance
or rehabilitation program approved for such purposes by a Federal , State , or local
health, law enforcement , or other appropriate agency ; and
g . Making a good faith effort to continue to maintain a drug - free workplace through
implementation, of paragraphs ( a) , (b) , ( c) , (d) , (e) , and (f) .
3 . Contractor will inform the Department of any additional sites for performance of work
under this agreement .
4 . False certification or violation of the certification may be grounds for suspension of
payment , suspension or termination of grants , or government- wide Federal suspension or
debarment . 45 C . F . R . 82 . 510 .
III . Certification Regarding Environmental Tobacco Smoke
Public Law 103 -227 , Part C - Environmental Tobacco Smoke , also known as the Pro -
Children Act of 1994 (Act) , requires that smoking not be permitted in any portion of any
indoor facility owned or leased or contracted for by an entity and used routinely or regularly
for the provision of health, day care , education , or library services to children under the age
of 18 , if the services are funded by Federal programs either directly or through State or local
governments , by Federal grant, contract, loan, or loan guarantee . The law does not apply to
children ' s services provided in private residences , facilities funded solely by Medicare or
Medicaid funds , and portions of facilities used for inpatient drug or alcohol treatment .
Failure to comply with the provisions of the law may result in the imposition of a civil
monetary penalty of up to $ 1 , 000 . 00 per day and/or the imposition of an administrative
compliance order on the responsible entity .
The Contractor certifies that it will comply with the requirements of the Act . The
Contractor further agrees that it will require the language of this certification be included in
any subawards that contain provisions for children ' s services and that all subgrantees shall
certify accordingly .
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IV . Certification Regarding Debarment , Suspension , Ineligibility and Voluntary
Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase " prospective lower tier participant " means the Contractor . ]
1 . By signing and submitting this document , the prospective lower tier participant is
providing the certification set out below .
2 . The certification in this clause is a material representation of the fact upon which
reliance was placed when this transaction was entered into . If it is later determined that
the prospective lower tier participant knowingly rendered an erroneous certification , in
addition to other remedies available to the Federal Government, the department or
agency with which this transaction originate may pursue available remedies , including
suspension and/or debarment .
3 . The prospective lower tier participant will provide immediate written notice to the
itted if at any time the prospective lower tier
person to whom this proposal is subm
participant learns that its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances .
4 . The terms " covered transaction , " " debarred , " " suspended , " " ineligible , " " lower tier
covered transaction, " " participant, " " person, " " primary covered transaction , " " principal , "
" proposal , " and " voluntarily excluded , " as used in this clause , have the meanings set out
in the Definitions and Coverage sections of rules implementing Executive Order 12549 ,
45 CFR Part 76 . You may contact the person to whom this proposal is submitted for
assistance in obtaining a copy of those regulations .
5 . The prospective lower tier participant agrees by submitting this proposal that , should the
proposed covered transaction be entered into , it shall not knowingly enter any lower tier
covered transaction with a person who is debarred , suspended, determined ineligible or
voluntarily excluded from participation in this covered transaction unless authorized by
the department or agency with which this transaction originated .
6 . The prospective lower tier participant further agrees by submitting this document that it
will include the clause titled " Certification Regarding Debarment , Suspension ,
Ineligibility and Voluntary Exclusion- - Lower Tier Covered Transaction , " without
modification , in all lower tier covered transactions and in all solicitations for lower tier
covered transactions .
7 . A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred , suspended ,
ineligible , or voluntarily excluded from covered transaction , unless it knows that the
certification is erroneous . A participant may decide the method and frequency by which
it determines the eligibility of its principals . Each participant may, but is not required to ,
check the Nonprocurement List .
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8 . Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this clause .
The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings .
9 . Except for transactions authorized in paragraph 5 of these instructions , if a participant in
a covered transaction knowingly enters into a lower tier covered transaction with a
person who is suspended, debarred, ineligible , or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal Government , the
department or agency with which this transaction originated may pursue available
remedies , including suspension, and/or debarment .
Certification
1 . The prospective lower tier participant certifies , by submission of this document , that
neither it nor its principals is presently debarred , suspended , proposed for debarment,
declared ineligible , or voluntarily excluded from participation in this transaction by any
Federal department or agency .
2 . Where the prospective lower tier participant is unable to certify to any of the statements
in this certification, such prospective participant shall attach an explanation to this
proposal .
V. Certification Regarding Lobbying
The Contractor certifies , to the best of his or her knowledge and belief, that .
1 . No Federal appropriated funds have been paid or will be paid by or on behalf of the
undersigned , to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress , an officer or employee of Congress , or
an employee of a Member of Congress in connection with the awarding of any Federal
contract, continuation , renewal , amendment, or modification of any Federal contract,
grant , loan , or cooperative agreement .
2 . If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency , a
Member of Congress , an officer or employee of Congress , or an employee of a Member
of Congress in connection with this Federally funded contract , grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form SF - LLL ,
" Disclosure of Lobbying Activities , " in accordance with its instructions .
3 . The undersigned shall require that the language of this certification be included in the
award document for subawards at all tiers (including subcontracts , subgrants , and
contracts under grants , loans , and cooperative agreements) who receive federal funds of
$ 100 , 000 . 00 or more and that all subrecipients shall certify and disclose accordingly .
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4 . This certification is a material representation of fact upon which reliance was placed
when this transaction was made or entered into . Submission of this certification is a
prerequisite for making or entering into this transaction imposed by Section 1352 , Title
31 , U . S . Code . Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $ 10 , 000 . 00 and not more than $ 100 , 000 . 00 for each such
failure .
VI . Disclosure Of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity , whether subawardee or
prime Federal recipient , at the initiation or receipt of a covered Federal action , or a material
change to a previous filing, pursuant to title 31 U . S . C . section 1352 . The filing of a form is
required for each payment or agreement to make payment to any lobbying entity for
influencing or attempting to influence an officer or employee of any agency , a Member of
Congress , an officer or employee of Congress , or an employee of a Member of Congress in
connection with a covered Federal action . Use the SF - LLL - A Continuation Sheet for
additional information if the space on the form is inadequate . Complete all items that apply
for both the initial filing and material change report . Refer to the implementing guidance
published by the Office of Management and Budget for additional information .
1 . Identify the type of covered Federal action for which lobbying activity is and/or has been
secured to influence the outcome of a covered Federal action .
2 . Identify the status of the covered Federal action .
3 . Identify the appropriate classification of this report . If this is a follow-up report caused
by a material change to the information previously reported , enter the year and quarter in
which the change occurred . Enter the date of the last previously submitted report by this
reporting entity for this covered Federal action .
4 . Enter the full name , address , city , state and zip code of the reporting entity . Include
if known . Check the appropriate classification of the reporting
Congressional District,
entity that designates if it is , or expects to be , a prime or sub - award recipient . Identify
the tier of the subawardee , e . g . , the first subawardee of the prime is the 1st tier .
Subawards include but are not limited to subcontracts , subgrants and contract awards
under grants .
5 . If the organization filing the report in Item 4 checks " Subawardee " , then enter the full
name , address , city , state and zip code of the prime Federal recipient . Include
Congressional District , if known .
6 . Enter the name of the Federal agency making the award or loan commitment . Include at
least one organizational level below agency name , if known . For example , Department
of Transportation , United States Coast Guard .
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7 . Enter the Federal program name or description for the covered Federal action ( Item 1 ) .
If known, enter the full Catalog of Federal Domestic Assistance ( CFDA) number for
grants , cooperative agreements , loans , and loan commitments .
8 . Enter the most appropriate Federal Identifying number available for the Federal action
identified in Item 1 ( e . g . , Request for Proposal (RFP ) number , Invitation for Bid ( IFB )
number , grant announcement number, the contract grant , or loan award number, the
application/proposal control number assigned by the Federal agency) . Include prefixes ,
e . g . , " RFP -DE - 90 - 00 L "
9 . For a covered Federal action where there has been an award or loan commitment by the
Federal agency , enter the Federal amount of the award/loan commitment for the prime
entity identified in Item 4 or 5 .
10 . ( a) Enter the full name , address , city , state and zip code of the lobbying entity engaged
entity identified in Item 4 to influence the covered Federal action .by the reporting
(b) Enter the full names of the individual ( s) performing services , and include full address if
different from 10 (a) . Enter Last Name , First Name and Middle Initial (MI) .
11 . Enter the amount of compensation paid or reasonably expected to be paid by the
reporting entity (Item 4 ) to the lobbying entity (Item 10 ) . Indicate whether the payment
has been made (actual) or will be made (planned) . Check all boxes that apply . If this is
a material change report, enter the cumulative amount of payment made or planned to be
made .
12 . Check the appropriate boxes . Check all boxes that apply . If payment is made through
an in-kind contribution , specify the nature and value of the in -kind payment .
13 . Check the appropriate boxes . Check all boxes that apply . If other, specify nature .
14 . Provide a specific and detailed description of the services that the lobbyist has
performed , or will be expected to perform , and the date (s ) of any services rendered .
Include all preparatory and related activity, not just time spent in actual contact with
Federal officials . Identify the Federal official ( s) or employee (s ) contacted or the
officer ( s ) , employee ( s ) , or Member(s ) of Congress that were contacted .
15 . Check whether or not a SF - LLL - A Continuation Sheet ( s ) is attached .
16 . The certifying official shall sign and date the form, print his/her name , title , and
telephone number .
15
Disclosure Of Lobbying Activities
(Approved by 01r113 ti3�t -t144E)
Complete this form to disclose lobbying ai»tivil,ies puirsuarit to 31 U . S .C , 1352
P.' . Ty = of F:: a ; ; Ction: : s»:s of Federal ::zcr : v. Rcpdrtypa:
Fit
-contract � a. � C� "r� rr � w r, ,� at w'� C � a . It !Iial Ming
b, t� Znttje
�.� cooperaVve agoree t'ien: ; m� . l ss-hYPard
k °1. ar For ?material Change Only:
a ^ guarantee
f, tea ^ Yew Quarti r
Cate Cf` Lasl Report:
l ane and address of Rem ting Entity: b, )f Report':"g l nt>>y in A.'o . r is � d�� E titer I ; 3rtte
and r A ?sF; s dr Ptimte :
Prim
; . Tier (if kro ;rn� < .�
-Congressional Diridot (:f {noSY^ +flnpr 5 iflne l Distriv, 4 kn(A
d, Federal CQ#artniei)VAgendy, i+»delral Rrcgra n I~ wA C, c� ! ` pion :
t F0A Kt nber i air ' , able)
3. 9 Tow
It it I
I*ederalo ttiumber :` yno + +j d� �rard .�aiount iif l+i? �rtn
a. Name and AFldress of L cbhx<rg Entity b , ndjv:, J w 3 :5 P_-'orn� - y SeerNr : es (At cfF address W
Itt
`indi iedaf, tastna rme, f tram€e, lW drifempl from Nb 900 i (fa tzame, fr;�t name. kill ,
ao' f=; rrSei
Any: Lt r a.y�ir ^t heap ear lf,rf 3p Iy3: 13 , Type of F'ay *nent (chock a*
-n al : Planned a. relainer
b, € nz.Airr've fwe
li . Form of F;Ftr nif chec . err thaf e p"A C: corrM(55ion
a. cash � eF, defierred
b. n-4 ^• ; spe �' = i:3t : - ILI l f, iher; SY_�ify:
aa
` 4 , Brief IQwr`es :Ntfon of ;Rlwiczes Performed onto be Performedar�J 039e(s) of See4ces, ir` duding opuier(s.), ent car
{c lti fl Cx+R'BY:iAC , ifl .:.• .�?ffgl£t1t Ini Y8t 7 3ti �k'� " '3C wC:`? �i i '7 �«+�ss3 tt- ? SF L1.1*A arc �vvc I i ;�:
. Caj rf intrat:ton heet's;i P•Llwlw• 1 .aIt3 shed: yes No
four tiort r s:_,;t ' {i throe n ft4s fora) fs authorized by SFa ^.ature.
I 31 is St C. Wit:" . . ` S' `)`his dis=y;os .ire oflobl��
at
amrifes is a rnatert; repre�fat:»< t r� F faF t opon which Pvni tvarr
relianoe ivas Cl-aced b^rt the tier a e 4hen this trwi, ac;ian
was made car ent& ed into . TO � disC�C•a" ufe is required fit�:
pursuant to 31 rs . S. C . 1352 , This information wit :: Ire
reported to :he Cor'gressse. nu-annualliy and will bs Telephone 'lo: Date; IF �
ZV for public.ins.p Of3n #yin re(Fs,cv: 1'`i?� :!t ! 10 Fite
tie required o : c> : zure shall Je sib:.^wt _ a t� i"A penalty of
i!!'�t less, 7icon : • + n [ � e, t rs t r 0F. A:.M 'of F
s�:h failure ,
IF
F I
Federal rat tis _ Gntj , tIihorized fof Loca ' Rteo;�� �
IF IF .
tandartiorrn < ? LL
�1.
I,
16