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U.S. DEPARTMENT OF JUSTICE
<br />� OFFICE OF JUSTICE PROGRAMS
<br />OFFICE OF THE COMPTROLLER
<br />CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
<br />OTHER RESPONSIBILITY MATTERS; AND DRUG -FREE WORKPLACE REQUIREMENTS
<br />Applicants should refer to the regulations cited below to determine the certification to which they are required to
<br />attest. Applicants should also review the ih9tructions for certification included in the regulations before completing this
<br />from. Signature of this form provides for compliance with certification requirements under 28 CFR Part 69, "New
<br />Restrictions on Lobbying" and 28 CFR Part 87, "Government -wide Department and Suspension (Nonprocurement) and
<br />Government -wide Requirements for Drug -retie Workplace (Grants)." The certifications shall be treated as a material
<br />representation of fact upon reliance will be placed when the Department of Justice determines to award the
<br />covered transaction, grant, or cooperative agreement.
<br />1. LOBBYING
<br />As required by Section 1352, Title 31 of the U:6. Code, and
<br />implemented at 28 CFR Part 69, for ersons_ AnterinqInto a
<br />gqrant or cooperative agreement over 9100,000, as defined at
<br />28 CFR Part 69, the applicant certifies that:
<br />(a) No Federal appropriate funds have been paid or will be
<br />paid, by or on behalf of the undersigned, to an. person for in-
<br />fluencing or attempting to influence an officer tir employee of
<br />any agency, a Member of Congress, an officer or employee of
<br />Congress, or an employee of a Member of Congress in con-
<br />nection with the making of any Federal grant, the entering into
<br />of any cooperative agreement, and extensiah, continuation,
<br />renewal, amendment, or modification of any Federal grant or
<br />cooperative agreement;
<br />(b) If any funds other than Federal appropriated funds have
<br />public (Federal State, or local) transaction or contract under a
<br />public transaction; violation of Federal or State antitrust
<br />statutes or commission of embezzlement, theft forpCry,
<br />bribery, falsification or destruction of records, making false
<br />statements, or receiving stolen property;
<br />(c). Are not presently indicted for or otherwise criminally or
<br />ciwllyy charged by a governmental emit (Federal, State, or
<br />locaq with commission of any of the offyenses enumerated in
<br />paragraph (1)(b) of this certification; and
<br />d) Have not within a three-year period preceding this applica-
<br />ion had one or more public transactions (Federal, State, or
<br />local) terminated for cause or default; and
<br />B. Where the applicant is unable to certify to any of the
<br />statements In this certification, he or she shall attach an
<br />explanation to this application.
<br />been paid or will be paid to any person for Influencing or at-
<br />tempting to influence an officer or employee of doV agency, a
<br />Member Congress, Congress,
<br />of an officer or employee of or
<br />an employee of a Member of Congress in correction with this
<br />3. DRUG -FREE WORKPLACE
<br />(GRANTEES OTHER THAN INDIVIDUALS)
<br />Federal grant or cooperative agreement, the and rsigned shall
<br />"Disclosure
<br />complete and submit Standard Form - LLL, of
<br />Lobbying Activities; in accordance with its instrudtlons;
<br />As required by the Drug Free Workplace Act of 1988, and
<br />implemented al 28 CFR Part 67, Subpart F, for
<br />((c) The undersigned shall require that the Ian beige of this car-
<br />fiflcalion be included in the documentsfbr all
<br />grantees as
<br />defined at 28 CFR Part 67 Sections 67.615 and 67.620-
<br />award subawards
<br />at all tiers (including subgrants, contracts under grants and
<br />A. The applicant certifies that it will or will continue to provide
<br />a drug -free workplace by:
<br />cooperative agreements, and subcontracts) and that all sub -
<br />recipients shall certlty and disclose accordingly.
<br />(a) Publishing a statement notifying employees that the
<br />unlawful manufacture, distribution, dispensing,. possession, or
<br />a controlled Is the
<br />RESPONSIBILI'T f MATTERSON, AND OTHER
<br />use of substance prohibited in grantee's
<br />employees forr of such prohibition; will be taken against
<br />(DIRECT RECIPIENT)
<br />violation
<br />As required b Executive Order 12549 pggbarment and
<br />Suspension, and Implemented at 28 CFR fJrt for
<br />Suspension,
<br />( Establishing an on -going drug -free awareness program to
<br />iNorm employees about -
<br />- , prospec•
<br />in primarny/ covered transactions; as defined at
<br />28 CpFR Part 67, Section 67.510-
<br />(i) The dangers of drugs abuse in the workplace;
<br />A. The applicant certifies that it and its principals:
<br />(2) The grantee's policy of maintaining a drug -free workplace;
<br />(a) Are not presently. debarred, suspended, proposed for debar-
<br />(3) Any available drug counseling, rehabilitation, and employee
<br />assistance programs; and
<br />ment declared ineligible sentenced to a denial of Federal
<br />benelits by a State or federal court, or voluntarily excluded
<br />(4) The penalties that may be imposed upon employees for
<br />from covered transactions by any Fedefal department
<br />drug abuse violations occurring in the workplace;
<br />or agency;
<br />(b) Have not within attires -year period preceding this applica-
<br />(c) Making it a requirement that each employee to be engaged
<br />in per of the grant be given a copy of the state-
<br />tion been convicted of or had a civil judgment fendered against
<br />ment required by paragraph (a);
<br />them for commission of fraud or a criminal offense in connec-
<br />tion with obtaining, attempting to obtain, or perfofming a
<br />(d) Notitylng the employee in, the statement required by
<br />paragraph `a) that, as a condition of employment under the
<br />grant, the employee will-
<br />OJP FORM 4061/6 (3-91) REPLACES OJP FORMS 406112, 4062/3 AND 4061/4 WHICH ARE OBSOLETE.
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