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Home My WebLink AboutC02-149 US Dept. of HealthAPPLICATION FOR 12. DATE SUBMITTED: Applicant Identifier 08YCO023 C0�—' —t (—Z� FEDERAL ASSISTANCE 6/17/2002 1. TYPE OF SUBMISSION . DATE RECEIVED BY STATE: Sta a ApMeation Identifier ...Application Preopplication Constr cation Construction 4. DATE RECEIVED BY FEDERAL AGI Fedrral Identifier Non-Ci istruction Non -Construction 5. APPLICANr INFORMATION Legal Name: Eagle County Early Head Start Organ ational UnitEagle County Early Head Start Address (give city, county, state, and zip code) Name and telephone number of the person to be contacted on PO Box 660 matters Eagle, CO 81631 C t Kathleen Forinash 970-328-8858 Eagle Executive Director 7. TYPE OF APPLICANT (Enter appropriate letter in box) Q 6. EMPLOYER IDENTIFICATION NUMBER (EIN) 8 4 6 1 0 1 0 1 0 0 7 E A- State H. Independent School Dist. B. County 1. State Controlled Institution of Higher Learning C. Municipal I Private University S. TYPE OF APPLICATION X Continuation Revision New ❑❑ D. Township K. Indian Tribe E. Interstate L. Individual F. Intermunicipal M. Profit Organization If Revision, enter appropriate letter(s) in box(es): G. Special District N. Other (specify) A. Increase Award B. Decrease Award C. Increase Duration 9. NAME OF FEDERAL AGENCY D. Decrease Duration Other (specify): HHS- Adminstration ofr Children & Families 10.CATALOG OF FEDERAL I1. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: DOMESTIC ASSISTANCE 9 3 6 0 0 Eagle County Early Head Start TITLE: Early Head Start Supplemental 2002 COLA, Quality Improvement funds, TlfA 12. AREAS AFFECTED BY PROJECT le County, Colorado 13. PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICTS OF: Start Date Ending Date a Applicant 3rd District b. Project 3rd District 10/012001 9/30/2002 r 15. ESTIMATED FUNDING 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTFVE ORDER 12372 PROCESS? a. YES THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE a Federal S 12,278 00 TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON DATE b NO X❑ PROGRAM IS NOT COVERED BY E.O. 12372 OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW Is Applicant $ 3,070 .00 c State S 0.00 d Local S 0.00 e Other S 0 .00 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? f Program Income S 0 A0 Yes If"Yes," attach an explanation. El No g Total S 16,348 .00 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE i Typed Name of Authorized Representative b Title c Telephone number Michael Gallagher BoCC Chair _ ;''�+�. 970-329-8600 � Signa re of [h rued Re r s [alive '" 'epetp igned beIr BUDGET INFORMATIOP 'on -Construction Programs '0348-0044 ON113 App, :o �SEG :.'IBU ,O T SU� MA Grant P Program Catalog of Estimated Unobli ated Funds g Function Federal New or Revised Budget or Activity Domestic Federal Non -Federal Federal Non -Federal Total Assistance I. Program Operation 93.600 $12,278 $3,070 $15,348 2.T&TA 93.600 3. 4. 5. Totals $12,278 $3,070 $15,34( 6. Object Class Categories GRANT PROGRAM, FUNCTION OR ACCIVITY Total (1) o am O erati (2) T&TA (3) (4) a. Personnel $7,596 $7,596 b. Fringe Benefits $1,036 $1, 036 c. Travel d. Equipment e. Supplies f. Contractual $3,462 $3,462 g. Construction It. Other $184 $184 i Total Direct Charges (sum of 6a $12,278 $12,278 j. Indirect Costs k. TOTALS (sum of 6a - 6j) $12,278 $12,278 NONE US 7. Program Income Authorized for Local Reproduction Standard Form 424A (Rev. 7.97) Prescribed by OMB Circular A-10 08YCO023 / 0 2002 Eagle County Early Head Start Supplemental EHS Grant Application COLA, Qual Improvement funds, T/ ii will a'Ali, (a) Grant Prog (b) Applicant (c) State aw :k: (e) TOTALS ) Other Sourc S. NFS $3,070 $3,070 9. to. It. 12 TOTAL (sum of lines 88 a��df k Yy�f"y„ l i°S _.iti,t `.� 4 b i+a ., tal for Ist Ye 13. Federal $12,278 $3,070 d 'o L Kt.�k$i l t. 1st Quarter JYiSE' L M+6w *� 2nd Quarter 3rd Quarter $3 070 s.x .. h 4th Quarter $3,070 $3,070 $3,070 $3,068 14. Non -Federal $3,070 $768 $768 $768 $766 15. TOTAL (sum of lines 13 -14 $15,348 $3,838 S3,839 S3,338 $3,834 i;3CGTE$ECTIOti MDERALrUtD$VEEDfU FOR 341iNCE OF THE P20JA.,E (a) Grant Program FUTURE FUNDING PERIODS (Years) (b) First (c) Second (d) Third (e) Fourth 16. 17. 18. 19. "i O :AL (sum of lines 16-19) SECTION I - OTUER I311ll('E't' 1 iEC}RINIA 1'TON' -- 21. Direct Charges: 22. Indirect Charg 23. Remarks: Authorized for Local Reproduction Standard Fonn 424A (Rev. 7-97) Page 08YCO023 / 0 2002 Eagle County Early Head Start Supplemental EHS Grant Application COLA, Qual Improvement funds, T/ Eagle County Early Head Start Program Approach Form 08YCOO23 /000 / 2002 Funded Enrollment ""' ,�•: .,tom, ..� .�x...�� 1. Funded enrollment by program option: Center -based enrollment 0 Number of Pregnant Women: 0 Home -based enrollment 45 Combination option enrollment 0 Family child care enrollment 0 Other option enrollment 0 Total Enrollment 45 1. Program schedule number 1 2. Program option identification HB- 3. Funded enrollment 45 Complete #1-9'#or center-baY . yed faii5il childcare combination angother_optlons �--— 4a. Number of classes/groups/family child care setttings — — — - 4b. Double session 5. Number of hours of classes/groups/FCC setttings per child, per day 6. Number of days of classes/groups/FCC settings per child, per week 7. Number of days of classes/groups/FCC settings per child, per year B. Number of home visits per child, per year 9. Number of hours per home visit Complete #10-13 for home-based,options ... 10. Number of home visits per child, per year 44 —`- 11. Number of hours per home visit 1.5 12. Number of hours per home -based socialization experience 2 13. Number of home -based socialization experiences per child, per year 24 5/30/2002 1:46:40 PM Eagle County Early Head Start 08YCO023 / 000 / 2u02 Line Item Budget For Head Start and Early Head Start �V+GCi .� r Min 5M1 eke t 1 � � r �� "1��,�•4'g .:rV. Q � + � �R6 ,Ln � � �'� � �' .�:,x�' # k t•?l� hate # N �t�ie �ofi e = .. t1 •?y.�}ty,Q�3�'��"9�1`3�tiM'r Va„J��MTZ4�y��-7 ��w� ,. r�"S� �i `SW��p1r•�A x+i; � Wl+� � �,j.�i lilf�� u�%i �t^�(�Ilik Ch1�r+9p�+i4�1 }.�� v erg"i.'4h� ^Y•; riL+i� Jett � I 17 g tr h n 5"11„ ., a5 .: oY n M v s-"�� c'if"!� . aN'�+"Iah�n.Df �.� "hR�i '-i"!.u&ff{{ '7 ar,�'"n ('n'. s 1 Program Managers & Content Area Experts .� . ! }�0-p9 $1,841 $0 $0 0.95 2 Teachers/Infant Toddler Teachers 3 Family Child Care Personnel 4 Home Visitors $4,215 $0 $0 3.00 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 Fam(�Y dnd Conrt�t�nit Partnechps`J'els DF1eJ' Wry ?{ Vr1�' 10 Program Managers & Content Area Experts 11 Other Family & Community Partnerships Personnel h' Prog,�am R�s�«�i„arid Mar��gsstteta%`f��rspgjje "�`ar �-�� +„+ S �,.f z S" � � �,,. - ,_. *N .c, .+i„i F�3,. „a., r�z'�✓A. i-'�*titi'�'t(°'..�� -Lu �.yf+� Y'�` `t W k �;. v *R 3�.- � s2er{ - 12 Managers h GtF. _r lAt} 1 $1,175 $0 $0 0.75f 13 Staff Development 14 Clerical Personnel 15 Fiscal Personnel $365 $0 $0 0.40 16 Other Administrative Personnel 5/30/2002 1:46:40 PM Eagle County Early Head Start OBYCO023 1000 / 2u02 Line Item Budget For Head Start and Early Head Start *�4 4sUF90z r ; HSlIHS Cost for HS/EHS Cost for7-7 Training & Non -Federal Number of o s ]w] # kY L A.r 'Y i Program Operations Technical Assistance (Gash andin-kind) Employed �4 $M1S 1 kJ9 f rr �tA'�� to m .�.. ,ath �• ., 1u�s; AN- 17 Maintenance Personnel 18 Transportation Personnel 19 Other Personnel TOTAL PERSONNEL (6a) $7,596 $0 $0 5.10 5/30/2002 1:46:41 PM 3 Eagle County Early Head Start 08YCO023 / 000 / 2u02 Line Item Budget For Head Start and Early Head Start 1 Social Security(FICA), State Disability, Unemploym $581 $0 $0 2 Health/Dental/Life Insurance 3 Retirement $455 $0 $0 4 Other Fringe TOTAL FRINGE BENEFITS (6b) $0 aff Out -Of -Town Travel r AVEL (6c) d. E QUlUPPT 1 Office Equipment 2 Classroom/Outdoor/Home-based/FCC 3 Vehicle Purchase 4 Other Equipment TOTAL EQUIPMENT (6d) Eagle County Early Head Start OBYCO023 1000 12uO2 Line Item Budget For Head Start and Early Head Start Position HS,EHS Cost `„ oS or Training & Non -Federal Share P.rogranrOpeiatiors TechnicalAss�stance Kash and in-kmd) 4 Other Supphes TOTAL SUPPLIES (6e) f. CON TR ACTUAL — — -- 1 Administrative Services(e.g., Legal, Accounting) 2 Health/Disabilities Services $800 $0 $200 3 Food Service 4 Child Transportation Services 5 Training & Technical Assistance 6 Family Child Care 7 Delegate Agency Costs 8 Other Contracts $2,662 $0 $666 TOTAL CONTRACTUAL (6f) $3,462 $0 $866 F 1 New Construction 2 Major Renovation 3 Acquisition of Buildings/Modular Unites TOTAL CONSTRUCTION (6g) 5/30/2002 1:46:42 PM 5 [I Eagle County Early Head Start O8YCO023 /000 / 2002 Line Item Budget For Head Start and Early Head Start No F ederal Share r x Snpe ei'�Ta. �''� 'fi2.c� `�„u.�? (:Cash and in in ,.�, 3�m adr� x'��k-'2at'�'L,�`.�'.�+ ru �. z�+'ks�$'u'i'"� r ➢a y '"" s h, bTHER 1 Depreciation/Use Allowance 2 Rent 3 Mortgage 4 Utilities, Telephone 5 Building & Child Liability Insurance 6 Building Maintenance/Repair and Other Occupanc 7 Incidental Alterations/Renovations 8 Local Travel 9 Nutrition Services 10 Child Services Consultants 11 Volunteers $0 $0 $2,204 12 Substitutes (if not paid benefits) 13 Parent Services 14 Accounting & Legal Services 15 Publications/Advertising/Printing 16 Training or Staff Development $184 $0 $0 17 Other TOTAL OTHER (6h) $184 $0 $2,204 5/30/2002 1:46:42 PM 11 Eagle County Early Head Start INDIRECT COSTS OBYCO023 /000 / 2UO2 Line Item Budget For Head Start and Early Head Start k. TOTALS - ALL BUDGET CATEGORIES $12,278 5/30/2002 1:46:43 PM 7 U.S. DEPARTMENT OF HEAL TH AND HUMAN SERVICES COMPENDIUM OF REQUIRED CERTIFICATIONS AND ASSURANCES ASSURANCES - NON -CONSTRUCTION PROGRAMS Note. Certain of these assurances may not be applicable to your projector 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) rtle 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 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.0 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; (t) 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 off ohol abuse or alcol lism; 23, altd _ 27 9f tie P.ublic.Healih 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; (1) any other non-discrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) 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 A and Ill 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. 20 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 U.S.C. 276a to 2766-7), 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. 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 maybe 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.); (t) conformity of Federal actions to State (Clear Ai rj 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. WiN 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 assist 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 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 wane 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 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 goveming this program. 4 DRUG -FREE WORKPLACE REQUIREMENTS GRANTEES OTHER THAN INDIVIDUALS By signing andlor 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 goverment -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 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 certficadon. Grantees' attention is called, in particular, to the following definitions from these rules: "Controlled substance" means a controlled substance in Schedules 1 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 polo 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 (N) 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 drug4ree 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 tnllowing 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 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. g) Making a good faith effort to continue to maintain a drug -free workplace through implementation of paragraphs (a) through (t). 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 govemments, 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 applicantlgrantee (for grants) certifies 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 certification be included in any subawards which subrecipients shag certify accordingly. 24 14, CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY MATTERS - 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 3year 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_ CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS (TO BE SUPPLIED TO LOWER TIER PARTICIPANTS) By skpWag. and subntiding his lower tier lrpposa, the prospeGVM IoweF 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. 25 '_V / 140Wl CERTIFICATION REGARDING LOBBYING FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE 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 Men 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 fads 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. to ove certiftcat* and assuranc �'i a June 18,_ 2002 Signature o ify * Date Chairman, Board o County Commissioners OttoRa9° Title Eagle County Government - Health & Human Services Applicant Organization 26 DISTRIBUTION Originals to: I. Contract Book 2. 3. 4. _Copies to: 1.Accounting 2. 3.