Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
This Certification is required by the regulations implementing Executive Order 12549, Debarment
and Suspension, 29 CFR Part 98, Section 98.510, Participant's responsibilities. The regulations were
published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211).
(BEFORE COMPLETING CERTIFICATION, READ ATTACHED INSTRUCTIONS WHICH ARE AN INTEGRAL PART
OF THE CERTIFICATION)
1. The prospective primary participant certifies to the best of its knowledge and belief, that it and its
principals:
a. Are not presently debarred, suspended, proposal for debarment, declared ineligible, or voluntarily
excluded from covered transactions by a Federal Department or agency.
b. Have not within a three-year period preceding this proposal been convicted of or had a civil
judgment 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 statues or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property:
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(Federal, State, or local) with commission of any of the offenses numerated in paragraph (1) (b) of
this certification; and
d. Have not within a three year period preceding this application/proposal had one or more public
transactions (Federal, State, or local terminated for cause or default.
2. When the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
Name of Organization __________________________ ___________________________________________
Address__________________________________________________________________________________
Authorized Signature ___________________________________________________
Title _______________________ _____________Date____________________
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective recipient of Federal assistance funds is
providing the certification as set out below.
2. The certification in this clause is a material representation of fact upon which reliance was placed when
this transaction was entered into. If it is later determined that the prospective recipient of Federal
assistance funds knowingly rendered an erroneous certification, in addition to other remedies available
to the Federal Government, the Department of Labor (DOL) may pursue available remedies, including
suspension and/or debarment.
3. The prospective recipient of Federal assistance funds shall provide immediate written notice to the
person to whom this proposal is submitted if at any time the prospective recipient of Federal assistance
funds learns that its certification was erroneous when submitted or has become erroneous by reason of
changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," ineligible," "lower tier covered
transaction," "participant," "person," "primary covered transaction, "principal," "proposal," and
"voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage
sections of rules implementing Executive Order 12549.
5. The prospective recipient of Federal assistance funds agrees by submitting this proposal that, should
the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier
covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this covered transaction, unless authorized by the DOL.
6. The prospective recipient of Federal assistance funds further agrees by submitting this proposal that it
will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion-Lower Tier Covered Transactions," without modification, in all lower tier covered transactions
in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded
from the covered transaction, unless it knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the eligibility of its principals. Each participant
may but is not required to check the List of Parties Excluded from Procurement or Non-procurement
Programs.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records
in order to render in good faith the certification required by this clause. The knowledge and information
of a participant is not required to exceed that which is normally possessed by a prudent person in the
ordinary course of business dealings.
9.
Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended,
debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other
remedies available to the Federal Government, the DOL may pursue remedies, including suspension
and/or debarment.
Certificate of Lobbying Activities
THE UNDERSIGNED CERTIFIES, TO THE BEST OF THEIR KNOWLEDGE AND BELIEF, THAT:
1.
No Federal appropriated funds have been paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of an agency, or 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 any 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 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 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 to be included in the
award documents for all (over $100,000) sub-awards at all tiers (including subcontracts, sub-grants
and contracts under grants, loans, and cooperative agreements) and that all (over $100,000) subrecipients shall certify and disclose accordingly.
THIS CERTIFICATION IS A MATERIAL REPRESENTATION OF FACT UPON WHICH RELIANCE WAS
PLACED WHEN THIS TRANSACTION WAS MADE OR ENTERED INTO. SUBMISSION OF THIS
CERTIFICATION ISA PREREQUISITE FOR MAKING OR ENTERING INTO THIS TRANSACTION IMPOSED
BY SECTION 1352, TITLE 31, U.S. CODE. ANY PERSON WHO FAILS TO FILE THE REQUIRED
CERTIFICATION SHALL BE SUBJECT TO A CIVIL PENALTY OF NOT LESS THAN $10,000 AND NOT MORE
THAN $100,000 FOR EACH SUCH FAILURE.
Name of Organization __________________________ ___________________________________________
Address__________________________________________________________________________________
Authorized Signature ___________________________________________________
Title _______________________ _____________Date____________________
Statement of Assurances
The undersigned party acknowledges and assures that (Vendor Name)
______________________________________________________________________________ and
all of its employees responsible for providing the services for which it has applied will abide and
comply fully with all state, federal, and local, laws, ordinances, rules, regulations and/or executive
orders, including but not limited to provisions of the laws listed below:
1. WIA Section 188, which prohibits discrimination against all individuals in the United States on
the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief,
and against beneficiaries on the basis of either citizenship/status as a lawfully admitted
immigrant authorized to work in the United States or participation in any WIA Title I-financially
assisted program or activity;
2. Title VII of the Civil Rights Act of 1964, as amended, which prohibits discrimination on the basis
of race, color and national origin;
3. Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination
against qualified individuals with disabilities;
4. The Americans with Disabilities Act (ADA) of 1990 which prohibits discrimination against
qualified people with disabilities based on disability;
5. The Age Discrimination Act of 1975, as amended, which prohibits discrimination on the basis of
age;
6. Title IX of the Education Amendments of 1972, as amended, which prohibits discrimination on
the basis of sex in educational programs;
7. 29 CFR Part 37 and all other regulations implementing the laws listed above. This assurance
applies to the operation of the WIA Title I-financially assisted program or activity, and to all
agreements the contractor makes to carry out the WIA Title I-financially assisted program or
activity. The undersigned understands that the United States has the right to seek judicial
enforcement of this assurance.
Name of Organization __________________________ ___________________________________________
Address__________________________________________________________________________________
Authorized Signature ___________________________________________________
Title _______________________ _____________Date____________________
Drug-Free Workplace Certification Statement
The Applicant will provide a drug-free workplace in accordance with the requirements of the Drug-Free
Workplace (DFW) Act, issued by the Office of Management and Budget, effective March 18, 1989.
The statute requires those who receive Federal funds in excess of $25,000 to certify to the agency
served that it will provide a drug-free workplace.
A drug-free workplace, as defined by the regulations, is a worksite at which the employees are
prohibited from the unlawful manufacture, possession, distribution, or use of a controlled substance.
Name of Organization __________________________ ___________________________________________
Address__________________________________________________________________________________
Authorized Signature ___________________________________________________
Title _______________________ _____________Date____________________
Small or Minority Business Verification
Note: To be submitted by Bidder wishing to be considered small business or minority business:
Bidders not wishing to be considered small or minority businesses are NOT required to complete this
form:
1.
Business:
A business is an activity entered into for the purpose of making a profit. Two (2) characteristic
elements of a business are regularity of activities and transactions and the production of
income.
2.
Small Business:
a. Current number of employees________________ (full time equivalent)
b. Annual Receipts: Tax Year 2011______________________________
Tax Year 2012______________________________
Tax Year 2013______________________________
3.
Minority Business:
Please list all Owners or Stockholders. For each Owner or Stockholder, list:
a. Name ______________________________________________
b. Address ____________________________________________
c. Percentage owned, if the owner or stockholder is a member of a minority group, the
minority group of which he or she is a member. _____________