HomeMy WebLinkAboutCertification C
U.S. DEPARTMENT OF JUSTICE
� OFFICE OF JUSTICE PROGRAMS
OFFICE OF THE COMPTROLLER
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they are required to
attest. Applicants should also review the instructions for certification included in the regulations before completing this
from, Signature of this form provides for compliance with certification requirements under 28 CFR Part 69, "New
Restrictions on Lobbying"and 28 CFR Part 67, "Government-wide Department and Suspension (Nonprocurement)and
Government-wide Requirements for Drug-Free Workplace (Grants)."The certifi
cations P ( } shall be treated as a material
representation of fact upon reliance will be placed when the Department of Justice determines to award the
covered transaction,grant, or cooperative agreement.
1. LOBBYING ubb lc (Federal .State,,cer local) tra a don or c tract under a
uglicc transaction;. violation or ederat or at �nUtrust
Asrequired b e tin 1352 Ttle 31 of the U.S. Code, an t iu es o commission f em a ement he , or
ipmploeDMDemr d at
o� FR rP�art 69, '�II r ns erntteerrinqq�into 3 qla' iiL ery falsification .or destruction o records, making �ae1srye
or cc000perattivveehe p9orerementt fieseha U�� as detineTl at 2tf c FR statements, or receiving stolen property,
a No Federal appropriateAre riot presentlyindicted for or ptherwis criminal or civil
funds have been paid or will be paid, ar ed by a ovem1n ntaI entity (Federal eptate, oor Io9al) wi hi)
(( or on behalf of the un ersi ned, to any erson for influencingom Sio t �an o tie offenses enumerate in ara ra h (1
by attempting to influencean fficer or erft�loyee of anyagency, (b)o this certiii'cation;and
a Member o Congress, an o icer or emp''oyee of Cogress br
an em loV a of a Member of Congress in connection with'the
makin of any Federal grant the entering into of any (,d).Havee riot within�a th ee-yaearc�iod eCeding hi apclicatio
coo pe ative agqreement, an extension, continuation, renewal, ter one r more ublid #r sa ti ns f ederal, �ta e, r local)
amendment, OF modification of any Federal grant or cooperative ermina a for taus or eau t; an
agreement;
B. Where the applicant is unable tocertify to anyof the
statements m this certification, ne or he shall attach an
b If an tf ds other than Federal a r riafed fundshav been expianaton to this application.
�I an�e e to a pp n fv any encinl or a�ee) e tool
ffduenceorWillo cer or ey o ee t an a in a e�T' na of
ress a cer or ern o ee o Con re o a a o e o
a l�ambel o� on res co ne tioo ,, h is a era n o pRUG FREE yypR�PLA��
�he c'ersic�Ded s al co p�e� anc� GRANTEES OTHER THAN INDIVIDUALS
u �etatiXant�ae 'ofm ��_ isclosure o' obyrng
c ivities,,i77in accordance with its instructions; As refireded b ZthgeC D u Frtree W r tllaacrteFAct off 1988, and
deoi an cL a FR Pa?P�Secflons t5�.615' asd 3i�r s, as
I he i ridergigne I sr it require that the la❑puape pt tins cer-
28
� Cation b�inGQded in the award documents fdt Irsubawards at I e a i� t nines that it will or win continue to provide a
allll itiers, includinr subgrants on rac unc�eer rant& an
rug- ee r�p�ace�'by:
cog eratw agree ens and Subcontracts) an trra a su -
recipients shalrce i and diisciose accoringty. 1
at tne
usekofui manufacture,
i su s arint butionce iotintpais i,.p hsesessioneeprr
�(i gtgioN,ANu U I rIttt employees,orviolatlorl oT uch prohibst on, will be akert against
s
•
�T�II��.�PIEN t) 1 1 tFL
(bt tstabiisnino a on-going drug-tree awareness program to
qqs required by Executive Order 112�5q9, Debarment nd orm emp oy s about-
Sau� e a� n,and implemented at.2ed 8 CFRo t 6i for prospective
(1)The dangers of drugs abuse in the workplace;
A. The applicant certifies that it and its principals: (2)The grantee's policy of maintaining a drug-free workplace;
(a) Are not presently, debarred. suspended, proposed for debar- aSslsistaynceeprograms ari�unseling, rehabilitation, and employee
ment declared ineligible, sentenced to a denial of Federal
benefits by a State or-Federal court, or voluntarily excluded (4)The penalties that may be imposed ucpon employees for drug
covered transactions byany
Federal department or agency; use v ola ions occurring in e a e,
bl Ln rp ri recedingthis the Mono t a recOtrirf grant thabt each gie a cpy ofto be esratem in
b Have no wth a three-year eriod eced n t is application n h Making ante A ) a given copy employee the s men
en convicted o r h a a civi ud a rendereda a st e req ired by paragraph e(a
r commission o,fraud r a cri i o ense in con ection WI
ootaining,attempting to ootain, or pe orming a t�hheg p t by
(d� q tifni/q)th�t, as corn iition of emplloymentt undergts�e grant,
p r Not a
e employ wi -
OJP FORM 4061/6(3-91)REPLACES OJP FORMS 4061/2,4062/3 AND 4061/4 WHICH ARE OBSOLETE.
(1)Abide by the terms of the statement;and
SeaTac HIDTA Task Force (Group 0-22)
(2),r a r Notify o Pie cn 4ri��ed n ri u occurnnr he the worrktipllace no 3 0 0 5 t h Ave, Suite 1300
a er an we ca en ar agys a er such con�ic�ion;
Seattle, WA 98109
e Notif�in the agency, in writin with calendar days after
e lyind notice a su ara aph q)? trot» an ernplo ee
Qr o dtwis retie ulna a�tua notic� ov. ucn convl ti n. Check there are workplace on file that are not identified
t pto e c nwc yfrIll
es st rovioticen �u inre� aa[ oIi STitP� oN' olmg u3sgic f{i�e or5ws ier 3 o q �t hho I nc shall .n lan thvenue._catiori a cttion 67a 630 tftthem r a ne
ulatiocn�s Pfovtdo srn t a granee tfiat is•
num er?s)'of each a ected grant; }rofa6e a f��ent o hJlcn sho it Iermata o witeh each ap licalion
may eleL to use JP Form 40 la.. bfa�es and tale �gencies
Tapk,n one. of the, following actions, within 30 calendar
respect to�anyy a nOlo ee cweho is sorconvI?p teo-graph (d)(1).
d)( w'm Check I- if the State has elected to complete OJP Form
4061/7,
(11 Taking aptproenriate verso nell .action a ain t such n
req�ili�c�men spof the Rehacbiliie���ena o fisyt3 Cos a endedathort�e Ittl ainEE r R8'17 IVIDUALS)
( )Rpequirina such em I to artici ate satistactoril ina dru As re uir dd b e Fp u Fre W r lacrte t of 19gB, and
purposes appropr ae aal 'maa e, orrioEd%r al ha,RN, en o rr en Ye rZgeale58 ateP rt Saect orls g�5 a d grl.8�%ntees, as
ncy;
Asa o dition f he grant,.I rtify that I will not en a e in
( Making a ggoodd faith effort to,continue to maintainunla
(b), (g), (d), or use of a controlle substance rn condition 2griy activity Ali
(e),and(f). a grant; an
sdThe'grantee may insert in the space,provided below the site B. If convinced of a criminal drug offense resulting,from a
fofr trTe ertormance of work done in connection with the violation occurring during the conduct of an rant activity, I will
eci is gram: qq
report the con icTion, in writing, within 10 ca endar d s of the
coact of Performance (Street address, city, country, state, zip conviction,to: pe artment of Justice Office o�Justice rograms,
code) ATTN: Control uesk, 633 Indiana Avenue, N.W., Washington,
D.C. 20531.
As the duly authorized representative of the applicant,I hereby certify that the applicant will comply with the above certifications.
1. Grantee Name and Address:
Renton Police Department
1055 South Grady Way
Renton, WA 98057
2. Application Number and/or Project Name 3. Grantee IRSNendor Number
DEA SeaTac HIDTA Task Force (Group D-22)
4. Typed Name and Title of Authorized Representative
Kevin Milosevich, Chief of Police - Renton Police Department
5. Signature 6. Date
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