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- U.S. DEPARTMENT OF JUSTICE
<br />OFFICE OF JUSTICE PROGRAMS
<br />0 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 instructions 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 Pail 87, "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 public (Federal, State, or local) transaction or contract under a
<br />public transaction; violation of Federal or State antitrust
<br />As required by Section 1352, Title 31 of the U,S. Code, and statutes or commission of embezzlement, theft forppCry,
<br />Implemented at 2B CFR Part 69, for arsons. itntedns�77 Into a bribery, falsification or destruction of records, making Talse
<br />grant or coopperadve agreement over $100,000, as de Had at statements, or receiving stolen property;
<br />28 CFR Part 69, the applicant certifies that:
<br />(c) Are not presently indicted for or othClwrse crim'nally or
<br />{a) No Federal appropit to funds have been laid or will be civlll charged bV a governmental an dty tl-ederal, Mate, or
<br />paid, by or on befhlalf of tna undersigned, to an V person for In- loM with commission of any of the offenses enumerated in
<br />uencing or attempting to influence an o car r employee of paragraph (i)(b) of this certification; and
<br />any agency, a Member of Cangreas, an officer Cpp:�gress or employee of
<br />Congress ar an employee of a Member of in con- (d) Have not within a three-year period preceding this applies -
<br />on wkth the making of any Federal grant, the anteing Into don had one or more public transactions (Federal, State, or
<br />of any cooperative agreement, and extension, continuation, local) terminated for cause or default; and
<br />renewal, amendment, or modtficadon of any FedereI grant or
<br />cooperative agreement; B. Where the applicant is unable to certify to Cnv of the
<br />statements In this cerdgcatlon, he or she shall attach an
<br />(b) If an� funds other than Faderel appropriated funds have explanation to this application.
<br />been pad or will ba paid ao any person for Influencing or at-
<br />temptin9 to Inouence an of car or employee of. anY agency, a
<br />MembeP of Congress, an officer or employee of Congress, or pRUG-FREE WTKPLACE
<br />an employee of a Member of Congress in connection with this GRANTEES OTHER THAN INDIVIDUALS)
<br />Federal grant w cooperative agreement, the uridgrsipned shall V 9
<br />co let
<br />Activitles run ascctho dasrridce w/ih Its Instructloons-losure of Implemented al 28 CFR Part 6 , Subpaartt f ogran1ees as
<br />degned at 26 CFR Part 67 Sections Subpart for
<br />and 67220-
<br />tc1 The undersigned shall require that the Ian 99va4e of this cer-
<br />iftcation be included in the award documentslore11 subaworda
<br />at all tiers (Including subgrants, contracts under grants and
<br />cooperative a reements, and subcontracts) and that all sub -
<br />recipients shall cerdty and disclose accordingly.
<br />2.EppDEBARMENT T1} SUSPENSION, AND OTHER
<br />(RDIRECT RE�I�IENT)
<br />As required by , Executive Order 12549 Eldbannent and
<br />Suspension, and
<br />l implemeeNnted at 28 CFR Pit 6 , for pprospec-
<br />28 CFR Part 67, SectP(ons67.covered transactions, as dehned at
<br />A. The applicant certifies that it and its principals;
<br />A. The applicant certifies that It will or will continue to provide
<br />a drug -free workplace by:
<br />unllawfull mannufacture, distribution irdis employees that the
<br />ppee g possession, 'or
<br />s
<br />use
<br />controlled
<br />nd pecifyluabsthe actions hat wl be the
<br />enragainst
<br />employees for violation of such prohibition;
<br />(bl Establishing an on -going drug -free awareness program to
<br />inform employees about-
<br />(1) The dangers of drugs abuse in the workplace;
<br />(2) The grantee's policy of maintaining a drug -free workplace;
<br />(3) Any available drug counseling, rehabllltagon, and employee
<br />aJ Are HOT presem, . Usudfreu, Flueper,usu, p,ul u vu IV, uauar assistance programs; and
<br />A)
<br />declared inaigible sentenced to a denial of Federal
<br />benefits by a State or federal court, or voluntarily excluded (4) The penaltles that maV be imposed upon employees for
<br />from covered transactions by any Federal department drug abuse violations occurring in the workplace;
<br />or agency; g
<br />(b) Have not within a three or period prscedin' this applies- in the p a omianceuiof the grrannthat be givenplaycopy of the state
<br />lion beenconvictedof or had a civil Judgment is (dared against ment required by paragraph (a);
<br />Non withrohialning, attem fling to obtain, oral rforrmin le connec-
<br />g p performing (d) Nodtyingg the employee in the statement required by
<br />pam raph'a) that, as a condition of employment under the
<br />grant, the employee will-
<br />OJP FORM 406116 (3.01) REPLACES OJP FORMS 40811% 4062/3 AND 406114 WHICH ARE OBSOLETE.
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