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<br />4D
<br />U.S. Department of Justice
<br />Office of Community Oriented policing Services
<br />Coifficons
<br />Regard4lig LoMMM; OeharmeA Swporsim and Other Responsrili ty Matters [lrg4ree iffiortftriar e
<br />Reruirelmo is Marlthriation with A#� Agencies; Now*piaer iq; and RBhM tie[.
<br />Although the Department of Justice has made every effort to simplify the application process, other provisions of Federal law
<br />require us to seek your certification regarding certain matters. Applicants should read the regulations cited below and the
<br />inslructiore; for certification included in the regulations to understand die requirements and whether they apply to a particular
<br />applicant. Signature of this form provides for compliancewith certification requirements under 28 CFR part 69, "New
<br />Restrictions on Lobbying." and 28 CFR Part 67, "Government- wide Debarment and Suspension (iJonprocurement) and
<br />Government -wide Requirements for Drug-free Workplace (Grants)," and the coordination and non -supplanting requirements
<br />of the Public Safety partnership and Community Policing Act of 1994. The certifications shalt tee treated as a material represen-
<br />tation of fact upon which reliance will be placed when die Department of justice determines to award the covered grant.
<br />t. Lobbying
<br />As required by Section 1352, Title 31 of the U.S. Code anti imple-
<br />mented at 28 CFR part 69, for persons entering into a grant or coop-
<br />erative agreement overM0,000, as defined at 28 CFR Pars 69, the
<br />applicant certifies that:
<br />A. No Federal appropriated funds have been paid or will be
<br />paid, by or on belialf of the undersigned, to any person for inilu-
<br />encing or attempting to hiflueuce an officer or employee of ally
<br />agency, a Member of Congr--s, an officer or employee of
<br />Congress, or an employee of a Member of Congress h connection
<br />wsnr the making Of any Federal grant; the entering into of any
<br />cooperalive agreement; and lie exteri,Sten, continuation, renewal,
<br />amendment or modification of any Federal grant or cooperative
<br />agreement;
<br />M If any funds Other than Federal appropriated funds have been
<br />paid or will be paid to any person for influencing or attempting
<br />to Influence an officer or eniployee of any agency, a Member of
<br />Congn--is, an officer or employee of Congress, or an employee of
<br />a Member of Congress in connection with this Federal grant or
<br />cooperative agreement, ileo undersigned shall complete and sub-
<br />mit Standard Form — LLL, "'IM- Insure of Lobbying Activities," I.n
<br />accordance with its Inmmaimis;
<br />C. The undersigned shall require that the language of this ceitifi-
<br />calien hr included in the zoom do`nsments for all subawanis at
<br />all tiers (Including s rbgraihts, contracts under grants and coopera-
<br />Rive agreements, and subcontracts) and that all sub-reciplents
<br />shall certify and disclose accordingly.
<br />2. Debarment, Suspension and tither Responsibility Matter&
<br />(Direct Recipienl)
<br />As rerpiin-1 by 1'xerrtive Cirder 72519, DLbarrn.-M and Si!spmsiar4
<br />and implemented at 28 CFR pare 67, for prospective participants in
<br />primary covered transactions, as defamed at 2B CFI2 Part 67, Flection
<br />67,5111—
<br />A.
<br />7.510—
<br />A. The applicant certifies that it and its principals:
<br />(i) Are not presently debarred, suspended, proposedd for
<br />debarment, declared ineligible, sentenced to a decrial of
<br />Federal benefits by a state or Federal court, or volruuarily
<br />excluded from covered transactions by any Federal depart-
<br />ment or agency:
<br />(it) Have not within a three-year period preceding thus appli-
<br />cation been convicted of or had a civil judgment residered
<br />against them for commission of fraud ora criminal offense in
<br />connection with obtaining, attempting to obtain, or perform-
<br />ing public (Federal, state or local) transaction or contract under
<br />a public transaction; violation of Federal or state antitrust
<br />statutes orcommission of embezzlement, theft, forgery,
<br />bribery, falsification ordestructian of records, making (Also
<br />statements, or receiving stolen property;
<br />(ill) Are not presently indicted for or otherwise criminally or
<br />civilly charged by a governmental entity (Federal, state or
<br />local) wIIll commission of any of the offenses enumerated in
<br />paragraph (A)(ii) of this ceriificalion; and
<br />(iv) Have not within a three-year period preceding this appli-
<br />cation had one or more public transactions (Federal, state or
<br />local) terminated for cause or default; and
<br />il. Where the applicant 119 unable to certify to any of the stake-
<br />ments in this certification, he or she shall attach an explamition ro
<br />this application.
<br />3, Drug, -Free Workplace (Grantees 01herThan [ndlvidualn)
<br />As required by (lie Drug -Free Workplace Act of 1988, and imple-
<br />mented at 28 CPR Part 67, Subpart F, for grantees, as defined at 28
<br />Clift Part 67, Sections 67.615 and 67.670 —
<br />A. The applicant certifies dual I will, or will continue to, provide
<br />a drug-free workplace by:
<br />fit 14n1,]ishing a slaternieni rrsiifying enirlcnyc: e_i at +.^
<br />unlawful manufactute, distribution, dispensing, possession or
<br />use of a mntoliecf substance is prohibited in the granlee's
<br />workplace and specifying the actions that will be taken against
<br />employees for violation of such prohibition;
<br />(ti) fislablislting 5th ah -going dnlg-foe awai'ftiiess progr.un to
<br />inform employees about —
<br />
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