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HomeMy WebLinkAboutC04-315 Colorado Department of Public Health and Environment – Early Head Start APPLICATION FOR `TE SUBMITTED: .., -v _ - Applicant Id FEDERAL ASSISTANCE 9/30/2004 08CH0149 1. TYPE OF SUBMISSION 3. DATE RECENED BY STATE: State Application Identifier Application Preapplication Construction ~ Construction 4. DATE RECEIVED B XD Non•Construction ~ Non-Construction Y FEDERAL AGENCY Federal Identther 5. APPLICANT INFORMATION Legal Name: HHS, Eagle County Early Head Start Organizational Unit: Department: Eagle County Health 8< Human Service Organizational DUNS: 084-024447 Division: arly Chikthood Services Address: Street: PO Box 660 Name and telephone number of the person to be contacted on matters involving this application (give area code) 551 Broadway Prefix: Mrs. First Name: Kathleen City: Eagle Middle Name: County: Eagle Last ame: Forinash State: CO Zip Code: 81632 Su a: Country: USA Email: kathleen.forinash@eaglecounty.us 6. EMPLOYER IDENTIFICATION NUMBER (EIN) Phone Number (give area code) Fax Number (give area code) 8 4 .~ 6 0 0 0 7 6 2 970-328-8858 970-328-8829 8. TYPE OF APPLICATION 7. TYPE OF APPLICANT (enter appropriate letter in box) ^ B New ~ Continuation Revision If Revision, enter appropriate letter(s) in box(es): ~ 8 Other (specify) Other (specify) 9. NAME OF FEDERAL AGENCY: HHS-Adminstration for Children & Families 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 9 3, 6 0 0 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: Continuation TITLE (Name of Program): Early Head Start 12. AREAS AFFECTED BY PROJECT (Cities, Counties, States etc.): Eagle County, Colorado 13. PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICTS OF: Start Date: 1/1/2005 Ending Date: 12/31/2005 a. Applicant3rd District b. Project 3rd District 15. ESTIMATED FUNDING 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a Federal S 398,794.00 a. YES THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE b Applicant S 99,699.00 TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON c State S 0.00 Date d Local s 0.00 b. NO ~ PROGRAM IS NOT COVERED BY E.O. 12372 OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW e Other S 0.00 f Program Income S 0.00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? g Total S 498,493.00 ~ Yes If "Yes," attach an explanation. ^X No 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED a. Authorized Representative Prefa First Name Tom Middle Name C. Last Name Stone Suffa b. Title BoCC Chair c. Telephone number 970-328-8506 d. Signature of Authorized Representative e. Date Signed 9/28/2004 Standarcl Fnrm d9d / fie., o ~nn~~ e~___~_ - ---..~ . ..-w.,ucu u~ vrvi~ I,000Idf H-7 UL BUDGET INFORMATION -Non-Construction Programs OMB Approval No. 0348-0044 ' ::::;. Grant Program ,. ., ..;:.., Catalog of Federal ~~~1>=~~`BUII~IIARY >_.;; _°: -~~ ~ : ~ _~:;;°. ° ~ :. ~ ..~~.. ..Qy ~::- ~ a ..:::~ :x`=., _.:~~~::~ . :y~-~ :~' ...:`'~_ ~~ .~ ~....~ ,F:; Function Domestic Assistance Estimated Unobligated Funds New or Revised Budget or Activity (a) Number (b) Federal Non-Federal Federal Non-Federal Total 1. Program Operation 93.600 $389,400.00 $99,699.00 $489,099.00 2. T&TA 93.600 $9,394.00 $9,394.00 3. 4. 5. Totals $398,794.00 $99,699.00 $498,493.00 6.Object Class Categories GRANT PROGRAM, FUNCTION OR ACTNRY (1) Program Operation (2) T&TA (3) (q) Total a. Personnel $230,140.00 $230,140.00 b. Fringe Benefits $122,892.00 $122,892.00 c. Travel $1,748.00 $1,748.00 d. Equipment e. Supplies $14 264 00 , . $14,264.00 f. Contractual $4,000.00 $4,000.00 g. Construction h. Other $16,356.00 $9,394.00 $25,750.00 i Total Direct Charges (sum of 6a - 6h) $389,400.00 $9 394.00 , $398,794.00 j. Indirect Costs k. TOTALS (sum of 6a - 6j) $389,400.00 $9 394 00 , . $398,794.00 7. Pro gram Income . .. .: a~~, ~~~~; :. .., ,„g - ~& ~` ~ `~` Authorized for Local Reproduction Standard Form 424A (Rev. 7-97) Prescribed by OMB Circular A-102 08CH0149 / 0 2005 HHS, Eagle County Early Head Start Basic EHS Grant Application Continuation .: ~h°~ :'T, a.~^."..i .M ~S~`!Rs~ii,~" ril 'i..,a;: `,K•~y4r~~,.3 ,,.• ~:^2\rFnk aH„s"'?5b>' ~ „r :i ~S~'~^i.f R° ~r~..~'.. (a) Grant Program (b) Applicant c State O (d) Other Sources (e) TOTALS 8. NFS $99 699 00 , . $99 699.00 , 9. 10. 11. 12. TOTAL (sum of lines 8-11) $99 699 00 , . $99,699.00 'F< Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 13. Federal $398,794.00 $99,698.00 $99,698.00 $99,698.00 $99,700.00 14. Non-Federal $99,699.00 $24,925.00 $24,925.00 $24,925.00 $24,924.00 15. TOTAL (sum of lines 13 -14) $498,493.00 $ 124,623.00 $124 623 00 $124 623 00 , . , . $124,624.00 'tR ~ ~„;, :x. a~'RtI~V/l i=-BU~t3 >~iE ll~~~ .±!KA~Mfi.i+ y ,.., ., g;;i r~'Wx rk,x -. ~~I7M~^, "~ J R .}. ~ -:7:<e'YPh- °. eH 5-~~ ~ ' : ~` . -i '- » "a • ~' > , ~ . . ,~ ; :: ~ : ..:v, u a ; aS • , 3 FUTURE FUNDING PERIODS (Years) (a) Grant Program (b) First (c) Second (d) Third (e) Fourth 16. 17. 18. 19. 20. TOTAL (sum of lines 16-19) « ~: ~ ~ ;:<d, . s . ~ ; z:."`.f<.,3 ~~ ;S.^t ~,.'<'t'~,Wa,'.Y°~~°,~''iab.,.r , ~z.rc '",'~. ti~a,~ a ~ ~ ., ~ ~ ~ °N; z 21. Direct Charges: 22. Indirect Charges: 23. Remarks: Authorized for Local Reproduction Standani Form 424A (Rev. 7-97) Paget 08CH0149 / 0 2005 HHS, Eagle County Early Head Start Basic EHS Grant Application Continuation Eagle County Early Head Start Budget Justification -6`~ year January 1, 2005 through December 31, 2005 a. Personnel (object class 6a) Positions -total fte Federal Non-federal Early Head Start Director .9 fte .9 fte -0- (Health Coordinator/Family & Community Partnerships) Family Services Coordinator .75 fte .55 fte (Disabilities & Education Coordinator/home visitor supervisor) Home Visitors 4.5 fte (6 home visitors) 4.5 fte -0- Executive Director (Administrative) -0- .10 fte* Fiscal Technician .OS fte -0- .OS fte Group Socialization Assistance (5 hours per GS) .22 fte -0- Child care provider for Policy Council/Parent meetings .08 fte -0- TOTAL 6.45 fte 0.15 fte *documented by time sheets b. Fringe Benefits (Object class 6b) In addition to mandatory benefits, EHS provides health, dental, vision coverage and life insurance for individuals and families. The average cost of coverage is $16,860 per employee. Retirement benefits begin after one full year of employment. EHS's contribution is 6% of gross salary. Fringe benefit costs are prorated according to the federaUnon-federal allocation of fte. c. Travel (object class 6c) This item represents out of county travel by the EHS Director and Family Services Coordinator to participate in regional meetings and for program coordination with the Roaring Fork portion of Eagle County which is separated from the Eagle River Valley by 55 miles and which must be reached by travel through another county. Federal Cost: 2120 miles ~a .345 = 731 Meals x 3 w/El Jebel staff= 135 CHSA meeting = 882 1,748 d. Equipment (object class 6d) No equipment purchases are planned for this program year e. Supplies (Object class 6e) Federal Costs: Office supplies 700 Home visit materials (average of 85.64 per enrolled child) 3 854 Policy Council materials X400 Parent Meeting materials 200 Food for group socialization & parent meetings 5 600 X Food for Health Advisory Committee 160 Group Socialization materials 2,000 Replenishing lending library materials 1,000 Staff references 350 Total 14,264 Eagle County Early Head Start Budget Justification -6"' year January 1, 2005 through December 31, 2005 f. Contractual (object class 6f) Program evaluator & mental health consultation 4000 Training & Technical assistance (program anticipates same level of funding 9,394 for yeaz five 2004 g. Construction (object class 6g) The program has no plans for construction costs. h. Other (class object 6h) Utilities, Telephone: 7 cell phones @ $50/month 4,200 Local travel: Family related -home visits 6108 miles @ .345 1,054 Reimbursement to families Personnel car Family related -home visits, 45,554 miles @ .23 10,477 group social, parent meetings, EHS vehicles and special events Family related -home visits 2,500 miles @ .25 625 and group socialization Sub-total 51,162 miles 16,356 Non-Federal Costs: • Personnel and fringe benefits 12,487 • Training and technical assistance 7,200 • Use allowance: for 881 sq. ft. of office & storage space in a 14,500 sq.ft. 19,377 building owned by the applicant. Fair mazket value is $22/sq.ft. • Rent: 1,465 sq.ft. of donated space in the Basalt Middle School used for group 42,485 socializations, storage, and office space @ a value of $29/sq.ft. • Utilities & Telephone: Standard telephone service for 8 phone lines 2 1,500 approximately $15.63 per month • Volunteers: 180 hours at an average of $25/hour 4,500 • Parent volunteer services: inkind related to home visits and/or group 12,150 Socialization activities and family plan, includes parents reading to their children. Occurs between home visits or group socialization. 810 hours at an average of $15/hour. Total Non-Federal 99,699 Total Federal Budget 398,794 U. S, DEPARTMENT OF HEAL TH AND HUMAN SERVICES COMPEND/UM OF REQU/RED CERT/FICA TONS AND ASSURANCES ASSURANCES -NON-CONSTRUCT/ON PROGRAMS Note: Certain of these assurances may not be app/icable to your project or program. if you have questions, please contact the awarding agency, Further, certain Federal awarding agencies may require applicants to certify to additional assurances. if such is the case, you will be notified. As the duly authorized representative of the applicant, l certify that the applicant. 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufFcient to pay the non-Federal share of project costs) to ensure proper planning, management and completion of the project described in this application. 2. Will give the awarding agency, the Camptrol%r General of the United States, and if appropriate, the State, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award,• and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives. 3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of persona! or organizational conflict of interest, or personal gain. 4. Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding agency. 5. Wilt comply with the inter9'ovemmenta/ Personnel Act of 1970 (42 U.S.C. 4278-4763) relating to prescribed standards for merit systems for programs funded under one of the nineteen statutes or regulations specified in Appendix A of OPM=s Standards for a Merit System of Personnel Administration (5 CFR 900, Subpart F). 6. Will comply with all Federal statutes relating to non-discrimination. These include but are not limited to: (a) Title Vl of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the bases of race, color or national origin; (b) Title lX 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 Offrce and Treatment Act of 1972 (P.L. 92-255), as amended, relating fo non-discrimination on the basis of drug abuse; (~ the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to non-discrimination on the bases of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as amended, relating to confidentiality of the alcohol and drug abuse patient records; (h) Title Vll of the Civil Rights Act of 1968 (42 U.S.C. 3601 et seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (l) any other non-discrimination provisions in the specific statute(s) under which app/ication for Federal assistance is being made; and Q) the requirements of any other non-discrimination statute(s) which may apply to the application. 7. Will comply, or has already complies, with the requirements of Titles ll and 111 of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P. L. 91-646) which provide for fair and equitable treatment of persons displaced or whose property is acquired as a result of Federal or Federal/y assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 20 8. Will comply with the provisions of the Hatch Act (5 U.S.C. 1501-1508 and 73247328) which limit the political activities of employees whose principal employment activities are funded in whole or in part with Federal funds. 9. Will comply, as applicable, with the provisions of the Davis-Bacon Act (40 U.S.C. 276a to 276a-7), the Copeland Act (40 U. S. C. 276c and 18 U. S. C. 874), and the Contract Work Hours and Safety Standards Act (40 U. S. C. 327-333), regarding labor standards for Federally assisted construction subagreements. 10. Wi/I comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to participate in the program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10, 000 or more. 11. Will comply with environmental standards which may be prescribed pursuant to the fol%wing: (a) institution of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO > 1988, (e) assurance of project consistency with the approved State management progrem developed under the Coastal Zone Management Act of 1972 (16 U S. C. 1451 et seq.); (t) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the C/ear Air Act of 1955, as amended (42 U. S. C. 7401 et seq.); (g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended, (P. L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205) 12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assisf the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 U.S.C. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects invo%d in research, deve/opment, and related activities supported by this award of assistance. 15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 US. C. 2131 et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other activities supported by this award of assistance. 16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et se prohibits the use of lead based paint in the construction or rehabilitation of residence structures.hich 17. Will cause to be performed the required financial and compliance audits in accordance with the single Audit Act of 1984. 18. WiII comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program. 21 DRUG-FREE WORKPLACE REQUIREMENTS GRANTEES OTHER THAN INDIVIDUALS By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below. This certification is required by regulations implementing the Drug-Free Workp/ace Act of 1988, 45 CFR, Part 76, Subpart F. The regulations published in the January 31, 1989 Federal Register, require certification by grantees that they will maintain adrug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when HHS determines to award the grant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination of grants, or government-wide suspension or debarment. Workplaces under grants, for grantees other than individuals, need not be identified on the certification. if known, they may be ident~ed in the grant application. if the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation oithe grantee's drug-free workplace requirements. Workplace identifications must include the actual address of buildings (or parts of building) or other sites where work under the grant takes p/ace. Categorical descriptions may be used (e.g. a// vehic%s of a mass transit authority of State highway department while in operation, State employees in each local unemployment office, performers In concert halls or radio studios}. if the workplace identified to HHS changes during the perfomtance of the grant, the grantee shall inform the agency of the change(s), it previously identified the workplaces in question (see above). Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees' attention is called, in particular, to the fol%wing definitions from these rules: "Controlled substance" means a controlled substance in Schedules l through V of the Controlled Substances Act (21 USC 812) and as further defined by regulations (21 CFR, 1308.11 through 1308.15). "Conviction" means a finding of guilt {including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal of State criminal drug statutes; "Criminal drug statute" means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing use, or possession of any controlled substance; Employee" means the employee of a grantee directly engaged in the performance of work under a grant including: (i) All "direct charge" employees; (ii) all "indirect charge" employees unless their impact of involvement is insignificant to the performance of the grant,' and (iii) temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent contractors not on the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces). The grantee certifies that it will provide adrug-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; 22 b) Establishing adrug-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) The grantee's policy of maintaining adrug-free workplace; (3) Any available drug counseling, rehabilitation, employee assistance programs; and (4} The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; c) Making it a requirement that each employee to be engaged in the pertormance of the grant be given a copy of be statement required by paragraph (aJ; 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 emp/oyer of any criminal drug statute conviction fora violation occurring In the workplace no later than five days aRer such conviction; e) Notifying the agency in writing within ten days after receiving notice under subparagraph {d)(2), from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer or other designee on whose grant the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant,• >~ Taking one of the following actions within 30 days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted: (>) 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. 9) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a) through (f). 23 CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE Public Law 103-227, 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, early childhood development services, education or library services to children under the age of 18, if the services are funded by Federal program either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment,• service providers whose sole source of applicable Federal funds in medicare of medicaid,• or facilities where WIC coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. By signing this certification, the offeror/contractor (for acquisitions) or app/icant/grantee for certifies that the submitting organization will comply with the requirements of the Act and will not allow smoking within an ( grants) y portion of any indoor facility used for the provision of services for children as defined by the Act. The submitting organization agrees that it will require that the language of this certification be included in any subawards which subrecipients shall certify accordingly. 24 CERTIFICAT/ON REGARDING DEBARMENT, SUSPENS/ON AND OTHER RESPONSIBILITY MATTERS- PR/MARYCOVERED TRANSACTIONS By signing and submitting this proposal, the applicant, defined as the rima with 45 CFR Part 76 certifies to the best of his or her knowledge and believe that it and ~s principals.rdance (a) are not present/y deban-ed, suspended, proposed for debarment, dec/ared ineligib/e or vo/untari/ excluded from covered transaction by any Federal Department or agency,• Y (b) have not within a 3year period preceding this proposal been convicted or had a civil jud ement 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 contractgunder a public transaction: violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement, or receiving stolen property,• (c) are not presently indicted or otherwise criminally or civil/y charged by a (Federal, State or local) with commission of any of the offenses enumerated ~n v ammental entity of this certification; and p rogro h 1 b p ()() (d) have not within a 3year period preceding this application/ ro transaction (Federal, State or local) terminated for cause or defaultposal had one or more public The inability of a person to provide the certification required above will not necessarily result in denial of participation in this covered transaction. if necessary, the participant shall submit an exp/anation of why it cannot provide the certification. The Departmentrof Health and Human Services' (HHS) determination whether to enter into this transaction. However, failure of the ros ective participant to furnish a certification or an explanation shat! disqualify such person from participation in this transaction. p p Primary The prospective primary participant agrees that by submittin this entitled "Certification Regarding Debarment, Suspension, lne~gibility andsVoluntarll include the clause ry Exclusion -Lower Tier Covered Transactions, "provided below without modification in all lower tier covered transactions. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARYEXCLUSION -LOWER TIER COVERED TRANSACTIONS (TO BE SUPPLIED TO LOWER T/ER PARTICIPANTS) By signing and submitting his lower tier proposal, the prospective lower tier participant, as defined in 45 CFR, Part 76, certifies to the best of its knowledge and belief that it and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntaril excluded from participation in this transaction by any Federal department or agency. Y (b) where the prospective lower tier participant is unable to certify to any of the above, such prospective participant shall attach an explanation to this proposal. The prospective lower tier participant further agrees by submitting this proposal that it wil! include this clause entitled "Certification Regarding Debarment, Suspension, Ineligibility and Volunta Lower Tier Covered Transactions, " without modification in all lower tier covered transactions and in all solicitations for lower tier covered transactions. rY Exclusion - 25 CERTIFICATION REGARDING LOBBYING FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVEAGREEMENTS The undersigned certifies to the best of his or her knowledge and belief, that: (1) No Federal appropriate funds have been paid or will be paid, 6y 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, 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 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 influencing or attempting to influence an officer or employee or an agency, a member of congress, an ofFcer 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 Form to Report Lobbying," in accordance with its instructions. (3) 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, 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 p/aced Hhen 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 or not less than $10,000 and not more than $100,000 for each such failure. l hereby agre the above c ifications and assurances. Signatu o Certifying Official Title Applicant Organization g /~1~~ Date 26