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U.S. DEPARTMENT OF JUSTICE <br />OFFICE OF JUSTICE <br />f r OFFICE OF THE COMPTTROLLL RS <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 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 />upb is (Federal .State , r local} tra a lan arc tr et under a <br />As e uir d b e fi������ 13 z� Ttle 31 of the U..S. Cttode, aan��j c�,t"? trtansaction; commission rslo°latian of e�nal a �iai sn�itrust <br />imp a an a p ICa tmeriifi s8eth at'�66l dfnas atirilr� ieta2a RL 6s{Aten tints, or receity og s an property eeco� 's, hmaking r alsrYc <br />a) No Federal appropriate funds have been paid or will be paid, Char redi�oyt pare ovg indafaeld ntit sier or eeeeral($a6tctemioall�coel}ciWJl� <br />o{ or on behalf of ttie undersigned, to any person f r influencing gornjl, SIA fgan Mnea of�n= enumeQele Ih paragraph �1) <br />attempting to Influence an officer or employee aTan agency, {•b) o�f tshis cc ificatYon; and <br />a Member m C In ress, an officer or employee of Cor�gross, or <br />an emplayas o a Member of Con g eas m connection with the h <br />making of any Federal dOrant the entering into of any (ddNa�e nolo en �reetryaeaactenns sogaerlal9Stase pariaiooa�� <br />cooperative agreernpnt, an extension, continuation, renewal,(erminarec�forcauseorogefaunfsanag <br />amendment, or modification of any Federal grant or cooperative <br />agreement; <br />B Whe'e the a plic tis una le to c rtify to an f the <br />stat I'M a In thlsp c r�1 i,cation, e or s e shall atfac an <br />Ib If an pp ds other than Federal a pr hated fund hav ben exprana{ion to this appleioatlon. <br />,,W or vyvll� se aiq to an person fo ln��iencln or as.�+gim{' I'tg fo <br />itr uence an o cer ore po ee an a en a lett e o <br />U cess, ar{ e icer or empia�ee otaCo rR o a:s e plove o <br />ambor o on res a co ne Uon ATI, is e ora ran o <br />co eratly aged n na {he ���erslg ed s aII co p <br />eq y no (GRANT? OTHER THAN INDIVIDUALS) <br />u �nd efan ar orm isclosure o o b m <br />Ac ivities, In accordance with its instructions; As rerr��,uin�r d�i b 2�tphggeppptu Frre W rk larcteFq t of 1988 and <br />de�lnaedeatse28aPR Parc7nSe�cYlonsbp6.61a'odn%.t�p�s, as <br />I (JJ( <br />The ubnderCCiane s antiI rev�q/Lire be <br />u(t thega mettpgyTu eqaAI t this cer- <br />II I tilers. nal udee @n Sg afd�a n rac u"I r 1T r? ttpr sa <br />coorecipub- <br />ients shaal, cey ane c is'elose accorngy. <br />bMIA� `�'�l�(`iPENS I ON, ANU U1 HER <br />Assn ore ulred b Executive <br />ltSUrtler 5 9, baroment nil <br />Rt�Ii �aarf %ecionr�7 a1 re tranimplemented gt sectm�s 6a rdeilne arei49 <br />A. The applicant certifies that It and its principals: <br />a) Are not present) debarred, suspended, proposed fDr debar- <br />Ir�ent declared he igible, sentenced to a denial of F decal <br />benefits by a State or Federal court, or voluntarilV excluded rom <br />covered transactions by any Federal department or agency; <br />btu tna© pace y. <br />that It will or will Continue to provide a <br />9 P y <br />(a) P bllshfn a stat ��m'ent notlt to em a ace that the <br />ureakwllulamconutrorteucro'suhsrr}}rlbceiols {s'fi�lntson in4Qhsessian1 ear <br />emplolyses�oav$o{aflo�i oysuach p�tori'Igagitn; will be faeketn againsa <br />ib�o rnt�lpsnyees aboouf9aing drug -tree awareness program to <br />(1) The dangers of drugs abuse in the workplace; <br />(2) The grantee's policy of maintaining a drug-free workplace; <br />e't, sgna available ds ganoaunseling, renabnitatlon, and employee <br />(al7usev agaiaofiis et cult lny Ir�eftie aiQgkpriacfe n employees for drug <br />tt Mak'n it a re r meat t at each em to ee to e en ed i <br />(ba Have n.of w�th� 1 a then e-yeaf period �recedonlg tulisnapn'lic tio� thaaMe" 'anceabi �G gran be given a� cpy of he s�afimenr{ <br />}'' en convlcte o r h a cm udg e t ren e e a ai st a e req Iced by paragrap 11a); <br />comms on of rau r a on Ina o ense In con ectlon wI <br />otalmng, a{empting to o�italn, or per onroing a th t <br />th� Notif�yId th f as o coon Inion of emplsoy nenefnunoferat�ia grana , <br />(� ra ra <br />ee po <br />OJP FORM 406116 (3-91) REPLACES OJP FORMS 4061/2,4062/3 AND 4061(4 WHICH ARE OBSOLETE. <br />