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U.S. DEPARTMENT OF JUSTICE
<br />0 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 ihetructions 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 67, "Government -wide Department and Suspension (Nonprocurement) and
<br />Government -wide Requirements for Drug -Free 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 />public (Federal State, or local) transaction or contract under a
<br />transaction; Federal
<br />As required b Section 1352 Title 31 of the 41:6. Code, and
<br />q Y
<br />Implemented 28 CFR Par( 69, for entering Into
<br />Public violation of or State antitrust
<br />statutes or commission of embezzlement, theft forgery,
<br />at persons a
<br />grant or cooperative agreement over $t00,000, as defined at
<br />bribery, falsification or destruction of records, making all
<br />28 CFR Part 69, the applicant certifies that:
<br />statements, or receiving stolen property;
<br />p p
<br />(a) No Federal a proprlate funds have been aid or will be
<br />by or on behalf of the undersigned, to for In-
<br />(c). Are not presently indicted for or otherwise
<br />civilly charged by a governmental entity
<br />criminally or
<br />(Federal, State, or
<br />ppaid, arty person
<br />i]us cing or attempting to influence an officer r employee of
<br />local) with commission of any of the offenses
<br />enumerated in
<br />any agency, a Member of Congress, an officer or employee of
<br />paragraph (i)(b) of this certification; and
<br />Congress, or an employee of a Member of Congress In con-
<br />nectaon with the making of any Federal grant, the entering Into
<br />fd) Have not within a three-year period preceding this applica-
<br />tion had one or more public transactions (Federal, State, or
<br />of any cooperative agreement, and extension, continuation,
<br />local) terminated for cause or default; and
<br />renewal, amendment, or modification of any Federal grant or
<br />cooperative agreement;
<br />R. Where the applicant is unable to certify to any, of the
<br />bb If any funds other than Federal a ro riotfed funds have
<br />een or will be to any for influencing or
<br />statements in this certification, he or she shall attach an
<br />explanation to this application.
<br />paid paid persono at-
<br />tempting to influence an officer or employee of any agency, a
<br />Member of Congress, an officer or employee of Congress, or
<br />3. DRUG -FREE WORKPLACE
<br />an employee of a Member of Congress in connection with this
<br />(GRANTEES OTHER THAN INDIVIDUALS)
<br />Federal grant or cooperative agreement, the undersigned shall
<br />complete and submit Standard Form - LLL, 'Disclosure of
<br />Lobbying Activities," in its instructions;
<br />As required by the Dru Free Workplace Act of 1988, and
<br />accordance with
<br />implemented at 28 CFR art 67, Subpart F, for grantees as
<br />defined at 28 CFR Part 67 Sections 67.615 and 67.620-
<br />(o) The undersigned shall require that the Iangua�e of this cer-
<br />ftification be included in the award documents Tdr II subawards
<br />at all tiers (including subgrants, contracts under grants and
<br />cooperative agqreements, and subcontracts) and that all sub -
<br />recipients shalt certity and disclose accordingly.
<br />2. DEBARMENT SUSPENSION, AND OTHER
<br />RESPONSIBILIW MATTERS
<br />(DIRECT RECIPIENT)
<br />As required by Executive Order 12549 Debarment and
<br />Suspension, and implemented at 28 CFR Pit 67, for prospec-
<br />tive participants in primaryY covered transactions, as defined at
<br />28 CFR Part 67, Section 67.510-
<br />A. The applicant certifies that it will or will continue to provide
<br />a drug -free workplace by:
<br />(a) Publishing a statement notifying employees that the
<br />unlawful manufacture, distribution, dispensing possession, or
<br />use of a controlled substance is prohibited yin the grantee's
<br />workplace and specifyin, the actions that will be taken against
<br />employees for violation a such prohibition;
<br />0Establishing an on -going drug -free awareness program to
<br />orm employees about-
<br />(1) The dangers of drugs abuse in the workplace;
<br />A. The applicant certifies that it and its principals: (2) The grantee's policy of maintaining a drug -free workplace;
<br />(3) Any available drug counseling, rehabilitation, and employee
<br />(a) Are not presentlyy, debarred, suspended, proposed for debar- assistance programs; and
<br />men: declared inetlgible sentenced to a dental of Federal
<br />benefits by a State or Vederal court, or voluntarily excluded (4) The penalties that may be imposed upon employees for
<br />from covered transactions by any Federal department drug abuse violations occurring in the workplace;
<br />or agency;
<br />(c) Makingp it a requirement that each employee to be engaged
<br />(b) Have not within a three-year period preceding this applica- in the performance of the grant be given a copy of the state -
<br />ion been convicted of or had a civil judgment rendered against 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 performing a (d) Ngqotityingg( the employee in, the statement required by
<br />gaant,rahehema) that,yee will -a condition of employment under the
<br />OJP FORM 4061/6 (3-91) REPLACES OJP FORMS 4061/�, 4062/3 AND 406114 WHICH ARE OBSOLETE.
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