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HomeMy WebLinkAboutC05-209 COLA Funding - Early Childhood [7.. t! 0:'; . :),~ ;:. -2 2_ APPLlCA TION FOR 1\ .TE SUBMITTED: Applicant 08CH0149 FEDERAL ASSISTANCE 1. TYPE OF SUBMISSION 3. DATE RECENED BY STATE: State Applicatic Identifier Application Preapplication D Construction D Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier ~ Non-Construction D Non-Construction 5. APPLICANT INFORMA nON Legal Name: Eagle County Health & Human Services Organizational Unit: Department: Eagle County Health & Human Services Organizational DUNS: 084-024447 Division: Early Childhood Address: Name and telephone number of the person to be contacted on matters Street: 551 Broadwzv involving this application (give area code) POB 660 Prefix: I First Name: Kathleen City: Eagle Middle Name: County: Eagle Last Name: Forinash State: CO Zip Code: 81620 Suffix: Country: USA Email: kathleen. forinash@eaglecounty.us 6. EMPLOYER IDENTIFICATION NUMBER (EIN) Phone Number (give area code) Fax Number (give area code) [T] -~ 970-325-8858 970-328-8829 8. TYPE OF APPLICATION 7. TYPE OF APPLICANT (enter appropriate letter in box) ~ D New D Continuation Ej Revision If Revision. enter appropriate letter(s) in box(es): ~ Other (specify) Other (specify) 9. NAME OF FEDERAL AGENCY: ACF 10. CATALOG OF FEDERAL DOMESTIC [I]2] ยท ~ 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: ASSISTANCE NUMBER: COLA TITLE (Name of Program): Early Head Start ONE TIME FUNDING 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 I b. Project 3rd District 15. ESTIMATED FUNDING 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a Federal $ 16,043 .00 a. YES THIS PREAPPLlCATION/APPLlCATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON b Applicant $ 4,032 .00 eState $ o .00 Date b. NO 0 PROGRAM IS NOT COVERED BY EO. 12372 d Local $ o .00 D OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW e Other $ o .00 f Program Income $ o .00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? g Total $ 20,075 .00 DYes If "Yes," attach an explanation. 0 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 Prefix Chairman I First Name Am Middle Name Last Name Menconi ~-, -'" Suffix b. Title Chair, BoCC ( f\ \ c. Telephone number 970-328-8506 d. Signature ~f Authorized RepresentatiV\ <:~ 1m, .~ e. Date Signed 7-1;2,. ,$ ~~ Stan0'lrd Form 424 (Rev.9-2003) Prescribed by OMB Circular A-102 BUDGET INFORMATION -Non-Construction Programs OMS Approval No. 034B.{)044 Grant Program Catalog of Federal Estimated Unobligated Funds New or Revised Budget Function Domestic Assistance or Activity Number Federal Non-Federal Federal Non-Federal Total (a) (b) 1. Program Operation 93.600 $16,043.00 $4,032.00 $20,075.00 2. T& T A 93.600 3. 4. 5. Totals $16,043.00 $4,032.00 $20,075.00 GRANT PROGRAM, FUNCTION OR ACTMTY Total 6. Object Class Categories (1) Program Operation (2) T&TA (3) (4) a. Personnel $2,300.00 $2,300.00 b. Fringe Benefits $1,594.00 $1,594.00 c. Travel d. Equipment e. Supplies f. Contractual g. Construction h. Other $12,149.00 $12,149.00 i Total Direct Charges (sum of 6a - 6h) $16,043.00 $16,043.00 j. Indirect Costs k. TOTALS (sum of 6a - 6j) $16,043.00 $16,043.00 Authorized for Local Reproduction Standard Fonn 424A (Rev. 7-97) Prescribed by OMS Circular A-1 02 08CH0149 / 0 2005 Eagle County Health & Human Services Supplemental EHS Grant Application COLA, ONE TIME FUNDING (a) Grant Program (b) Applicant (c) State (d) Other Sources (e) TOTALS 8. NFS $4,032.00 $4,032.00 9. 10. 11. 12. TOTAL (sum of lines 8-11) $4,032.00 $4,032.00 Total for 1 st Year 1 st Quarter 2nd Quarter 3rd Quarter 4th Quarter 13. Federal $16,043.00 $4,011.00 $4,011.00 $4,011.00 $4,010.00 14. Non-Federal $4,032.00 $1,008.00 $1,008.00 $1,008.00 $1,008.00 15. TOTAL (sum of lines 13 -14) $20,075.00 $5,019.00 $5,019.00 $5,019.00 $5,018.00 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) 23. Remarks: Authorized for Local Reproduction Standard Form 424A (Rev. 7-97) Page2 08CH0149 / 0 2005 Eagle County Health & Human Services Supplemental EHS Grant Application COLA, ONE TIME FUNDING Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start 1 Program Managers & Content Area Experts $599 $0 $0 0.92 2 Teachers/Infant Toddler Teachers 3 Family Child Care Personnel 4 Home Visitors $1 ,368 $0 $0 4.50 5 Teacher Aides & Other Education Personnel 6 Health/Mental Health Services Personnel 7 Disabilities Services Personnel 8 Nutrition Services Personnel 9 Other Child Services Personnel --. Executive Director/Other Supervisor of HS Director 13 Head Start/Early Head Start Director 14 Managers $267 $0 $0 0.50 15 Staff Development 16 Clerical Personnel 6/30/2005 4:42:37 PM 3 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 1000 I 2005 Line Item Budget For Head Start and Early Head Start 17 Fiscal Personnel 18 Other Administrative Personnel .'-~-., 6/30/2005 4:42:37 PM 4 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start 19 Maintenance Personnel 20 Transportation Personnel 21 Other Personnel $66 $0 $0 0.05 TOTAL PERSONNEL (6a) $2,300 $0 $0 5.97 6/30/20054:42:38 PM 5 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start 1 Social Security(FICA), State Disability, UnemploymE $210 $0 $0 2 Health/Dental/Life Insurance $1,251 $0 $0 3 Retirement $133 $0 $0 4 Other Fringe TOTAL FRINGE BENEFITS (6b) $1,594 $0 $0 Staff Out-Of-Town Travel TOTAL TRAVEL (6c) Office Equipment 2 Classroom/Outdoor/Home-based/FCC 3 Vehicle Purchase 4 Other Equipment TOTAL EQUIPMENT (6d) Office Supplies 2 Child and Family Services Supplies 6/30/2005 4:42:38 PM 6 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start 3 Food Services Supplies 4 Other Supplies TOTAL SUPPLIES (6e) Administrative Services(e.g.,Legal, Accounting) 2 Health/Disabilities Services 3 Food Service 4 Child Transportation Services 5 Training & Technical Assistance 6 Family Child Care 7 Delegate Agency Costs 8 Other Contracts TOTAL CONTRACTUAL (6f) New Construction 2 Major Renovation 3 Acquisition of Buildings/Modular Unites 6/30/2005 4:42:38 PM 7 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start ~~, 6/30/2005 4:42:38 PM 8 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start Depreciation/Use Allowance 2 Rent $0 $0 $3,058 ~ 3 Mortgage 4 Utilities, Telephone 5 Building & Child Liability Insurance 6 Building Maintenance/Repair and Other Occupancy 7 I ncidental Alterations/Renovations $12,149 $0 $0 8 Local Travel 9 Nutrition Services 10 Child Services Consultants 11 Volunteers $0 $0 $974 12 Substitutes (if not paid benefits) -" 13 Parent Services 14 Accounting & Legal Services 15 P u bl ications/ Advertising/Printing 16 Training or Staff Development 17 Other TOTAL OTHER (6h) $12,149 $0 $4,032 6/30/2005 4:42:38 PM 9 Supplemental EHS Grant Application Eagle County Health & Human Services 08CH0149 I 000 I 2005 Line Item Budget For Head Start and Early Head Start I j. INDIRECT COSTS I I I I k. TOTALS - ALL BUDGET CATEGORIES $16,043 $0 $4,032 ,-~ 6/30/2005 4:42:38 PM 10 Eagle County Early Head Start 2005 COLA & ONE TIME FUNDING Budget and Budget Justification: Item Federal Funds N on-Federal Funds Community donated Cost of Living Adjustment (COLA) book program "Raising . 1 % COLA to salaries. $2,300 a Reader" for enrolled . Associated increase in fringe $1,594 families and their benefits. children: $974 TOTAL COLA $3,894 $974 One-Time Funding . Labor, material to construct and $600 Rent: minimum of 139 install interior gate and railing to square feet of donated secure children in group socialization space in the Edwards area. Annex used for group . Labor, materials and equipment $2,460 socializations, Policy rental necessary to remove existing Council and parent sod and gravel adjacent to sidewalk committee meetings @ prep and pour new concrete sidewalk a value of $22/Sq.ft.: tight to building. $3,058 . Labor, materials and equipment $2,200 rental necessary to regrade t playground. Area to be prepped, new soil imported and new sod installed. . Playground equipment & installation. $6,889 TOTAL ONE TIME FUNDING $12,149 $3,058 TOTAL REQUEST $16,043 $4,032 Budget Narrative COLA: All staffwill receive a 1 % percent cost ofliving adjustment to maintain the quality of current services. This increase reflects a permanent increase in Eagle County Early Head Start's pay scale for all Early Head Start employees. Eagle County Government completed a market survey in 2005 to assure competitiveness of salaries. ONE TIME FUNDING: The Edwards Annex is used for group socialization, Policy Council and Parent committee meetings as well as various training activities. Funding is requested for: . Inside of the Edwards Annex: currently EHS uses a number of rooms within the building (the infant-toddler room, a large dining room, kitchen, child care room for siblings and bathrooms). All the rooms are around a large common room that is open to the rest of the building. The program would like to add a rail and gate to enclose the open common room to keep children from running out into the rest of the building as they move from one room to the other. COST: $600.00 - 1 - Eagle County Early Head Start 2005 COLA & ONE TIME FUNDING Improvements to the playground including: . Replace a five foot wide x 30 ft long strip currently filled with small rocks (potential choking hazard) with a concrete pad. This will more than double the current 4' wide concrete sidewalk adjacent to the strip giving us a 9' x 30' concrete pad that could provide a wider area for toddlers to ride their push cars and pull wagons. The area is currently fenced and part of the playground area. COST: $2,460 . Leveling and resodding the grassy part of the playground because currently this area is very uneven with small holes that staff and parent sometimes trip into. The area is regularly used as it has the sensory tables, picnic tables and benches and it is the route for access to the rubber tiled (impact-absorbing surface) part of the playground. COST: $2,200 . Replacement of the current playground equipment with a "Tot Town Fun Center made from a galvanized steel frame covered by a strong UV stabilized molded plastic that meets all safety requirements and does not require concrete footing so it can be installed over the impact-absorbing surface already in place in the playground. Also requested would be the purchase and installation of a "Hide-away hut" also from Constructive playthings to provide more playground alternatives to accommodate the toddlers that come to groups. This equipment is substantially more stable and safe than the current equipment we use. COST: $6,889.00 Non-federal Share: The program will receive $974 in donated books from "Raising a Reader" for enrolled families and their children. Space in the Edwards Annex is donated. A minimum of at least 139 square feet of donated space is used for group socializations, Policy Council and parent committee meetings @ a value of $22/Sq.ft.: $3,058. - 2 - U.S. DEPARTMENT OF HEAL TH AND HUMAN SERVICES COMPENDIUM OF REQUIRED CERT/FICA TIONS AND ASSURANCES SF 4248 ASSURANCES - NON-CONSTRUCTION PROGRAMS Note: Certain of these assurances may not be applicable 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, I certify that the applicant: 1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability (including funds sufficient 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 Comptroller 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 personal 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. Will comply with the intergovernmental 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 VI 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 IX of the Education Amendments of 1972, as amended (20 US. 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 US. C. 794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of 1975, as amended (42 US.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 non-discrimination 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 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 VII 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; (/) any other non-discrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and 0) 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 /I and 11/ 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 Federally assisted programs. These requirements apply to all interests in real property acquired for project purposes regardless of Federal participation in purchases. 8. Will comply with the provisions of the Hatch Act (5 U. S. C. 1501-1508 and 7324-7328) 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 US.C. 276a to 276a-7), the Copeland Act (40 U.S.C. 276c and 18 US.C. 874), and the Contract Work Hours and Safety Standards Act (40 US.C. 327-333), regarding labor standards for Federally assisted construction subagreements. 10. Will 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 following: (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 11988; (e) assurance of project consistency with the approved State management program developed under the Coastal Zone Management Act of 1972 (16 U.s.C. 1451 et seq.); (f) conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear 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. e. 1271 et seq.) related to protecting components or potential components of the national wild and scenic rivers system. 13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation Act of 1966, as amended (16 uS.e. 470), EO 11593 (identification and protection of historic properties), and the Archaeological and Historic Preservation Act of 1974 (16 US.C. 469a-1 et seq.). 14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development, 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 U.S.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.e. 4801 et seq.) which prohibits the use of lead based paint in the construction or rehabilitation of residence structures. 17. Will cause to be performed the required financial and compliance audits in accordance with the single Audit Act of 1984. 18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program. 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 Workplace 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 a drug-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 identified 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 of the 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 place. Categorical descriptions may be used (e.g. all vehicles 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 performance of the grant, the grantee shall inform the agency of the changers), 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 following definitions from these rules: "Controlled substance" means a controlled substance in Schedules I 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 a drug-free workplace by: a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition; b) Establishing a drug-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) The grantee's policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, 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 performance of the grant be given a copy of be statement required by paragraph (a); d) Notifying the employee in the statement required by paragraph (a) that as a condition of employment under the grant, the employee will: (1) Abide by the terms of the statement; and (2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after 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; f) 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: (1) Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or (2) Requiring such employee to parlicipate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency. g) Making a good faith efforl to continue to maintain a drug-free workplace through implementation of paragraphs (a) through (f). CERTlFICA TlON 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 porlion 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 cerlification, the offeror/contractor (for acquisitions) or applicant/grantee (for grants) cerlifies that the submitting organization will comply with the requirements of the Act and will not allow smoking within any 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 cerlification be included in any subawards which subrecipients shall cerlify accordingly. CERTlFICA TlON REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MA TTERS - PRIMARY COVERED TRANSACTIONS By signing and submitting this proposal, the applicant, defined as the primary participant in accordance with 45 CFR Part 76 certifies to the best of his or her knowledge and believe that it and its principals: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transaction by any Federal Department or agency; (b) have not within a 3-year period preceding this proposal been convicted or had a civil judgement rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction: violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement, or receiving stolen property; (c) are not presently indicted or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this certification; and (d) have not within a 3-year period preceding this application/proposal had one or more public transaction (Federal, State or local) terminated for cause or default. 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 prospective participant shall submit an explanation of why it cannot provide the certification. The Department of Health and Human Services' (HHS) determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. The prospective primary participant agrees that by submitting this proposal, it will include the clause entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions, " provided below without modification in all lower tier covered transactions. CERTlFICA TlON REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS (TO BE SUPPLIED TO LOWER TIER PARTICIPANTS) By signing and submitting this 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 voluntarily excluded from participation in this transaction by any Federal department or agency. (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 will include this clause entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions, " without modification in all lower tier covered transactions and in all solicitations for lower tier covered transactions. CERTlFICA TlON REGARDING LOBBYING FOR CONTRACTS, GRANTS, LOANS AND COOPERA T1VE AGREEMENTS 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, 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, 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 officer or employee of congress, or an employee of a member of congress in connection with this Federal contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure 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 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 or not less than $10,000 and not more than $100,000 for each such failure. e above certifications and assurances. - 7- /;?as Date c,(';; rlf' /11! #w' Title lY,;/v4lj ,/J;::J#"1f! /) "' t-'::,-?-?l._~ / ~-$./C.!-7t-P-~ ff4s:-Lt? Applicant Organization