HomeMy WebLinkAboutGRANTEE-SUBGRANTEE FOR DOMESTIC PREPAREDNESS 911 YR 2004 $225,000.00 HOMELAND SECURITY
GEORGIA EMERGENCY MANAGEMENT AGENCY
SONNY PERDUE
GOVERNOR
CHARLEY ENGLISH
DIRECTOR
May 15, 2008
..
RE: FIPS #245-04196-01
GAN #2004-GE-T4-0012
Budget Worksheet #-1098-EQU
Augusta-Richmond County
Emergency Management Agency
Mr. Howard Willis
Director
Augusta-Richmond County
Emergency Management Agency
911 4th Street
Augusta, Georgia 30901
Dear Mr. Willis:
Enclosed is the Grantee-Subgrantee, Office for Domestic Preparedness (ODP) State
Homeland Security Grant Program FY04 Agreement. This agreement governs the procurement
and use of equipment being funded by ODP, to help your agency to prepare for and react to
acts of terrorism.
The amount of this agreement is $225,000.00. You may not exceed in either quantity
nor total dollar amount the items expressly approved for you to purchase, as shown on the
accompanying detailed budget worksheet(s).
Attached to the Grantee-Subgrantee Agreement are Exhibits A-G. Please review and
return signed originals of the Grantee-Subgrantee Agreement, Exhibit F, and Exhibit G, to the
attention of your grants manager with in 14 days of receipt of th is letter. Keep a copy of each
form for your records.
If you require further information as to the grantee package, please contact Pat Craig,
Grants Manager, at 404-635-7511. Thank you for your work on behalf of the citizens of Georgia.
Angi Ford
Public Assistance Director
af/dm
Enclosures
Post Office Box 18055 . Atlanta, Georgia 30316-0055
Phone (404) 635-7000 or toll-free in Georgia 1-800-TRY-GEMA . Fax (404) 635-7205
www.gema.state.ga.us
FISCAL YEAR 2004 HOMELAND SECURITY GRANT PROGRAM
GRANTEE-SUB GRANTEE AGREEMENT
The United States Department of Homeland Security, Office of Justice Programs, Office
for Domestic Preparedness (ODP) approved the application and awarded funding for
homeland security and law enforcement terrorism prevention to the Georgia Emergency
Management Agency (GEMA) on behalf of the State of Georgia, in accordance with the
Fiscal Year 2004 Homeland Security Appropriations Act. GEMA will maintain overall
responsibility and accountability to the federal government for the duration of the project.
GEMA, as Grantee, has awarded the amount of $225,000.00 to Augusta-Richmond
County Emergency Management Agency, as Subgrantee, in accordance with the Fiscal
Year 2004 Homeland Security Grant Program (HSGP).
Under this Agreement, GEMA will execute the interests and responsibilities of the
Grantee. The individual designated to represent the State is Charley English,
Authorized Grantee Official. The State has designated Ralph Reichert as the Program
Manager of this program. The Subgrantee's Authorized Official has authority to legally
bind the Subgrantee and will execute the interests and responsibilities of the Subgrantee.
The Subgrantee's Authorized Official is the person whose name appears on page four (4)
of this agreement and whose signature appears on page four (4) of this agreement.
1. The following exhibits are attached or attainable via the internet and made a part of
this agreement:
Exhibit A
Exhibit B
Exhibit C
Exhibit D
Exhibit E
Exhibit F
Exhibit G
United States Department of Homeland Security, Office of Justice
Programs, Office of the Comptroller's Financial Guide, found on
OJP's Web site: http://www.ojp.usdoj.gov.
United States Department of Homeland Security, Office of Justice
Programs, Office of Domestic Preparedness Grant Solicitation and
Application Guide for Fiscal Year 2004 Homeland Security Grant
Program, a copy of which is available on the OJP Web site:
http://www .ojp. usdoj .gov/ docs/fy04hsgp. pdf.
Georgia Emergency Management Agency FY 04 ODP/Georgia
Homeland Security Grant Instructions for the State Homeland
Security and Law Enforcement Terrorism Prevention Program
11-07-03, a copy of which is available on the GEMA Web site:
http://www.gema.state.ga.us.
Approved Detailed Budget Worksheet.
Payment Request Form.
Assurances - OJP Assurance Form 4000/3.
Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transactions. Drug-
Free Workplace Certification. Lobbying Certification OJP Form
4061/6.
2. The Subgrantee agrees to use allocated funds only as approved, to comply with the
terms, conditions and guidelines as stated within this agreement, and to request
reimbursement only for expenditures made in accordance with the Approved Detailed
Budget Worksheet (Exhibit D). Any change to this worksheet must be requested in
writing by the Subgrantee and must be approved by the Program Manager prior to the
execution of that change.
3. Federal funds provided under this program are for 100% reimbursement of all eligible
expenditures.
4. No elected or appointed official or employee of the Subgrantee shall be admitted to
any share or part of any benefit, directly or indirectly, from this agreement or from
the grant or sub grant awards. This provision shall not be construed to extend to any
contract made with a corporation for its general benefit.
5. If the Subgrantee violates any of the conditions of this agreement, including all
exhibits hereto, or of applicable federal and state law or regulation, GEMA shall
notify the Subgrantee that additional funds for the grant in connection with which the
violation occurred will be withheld until such violation has been corrected to the
satisfaction of GEMA. In addition, GEMA may also withhold or require repayment
of all or any portion of the financial award which has been or is to be made available
to the Subgrantee for other projects under this program, this or other agreements, and
applicable federal and state regulations until adequate corrective action is taken.
6. The Subgrantee agrees that federal or state officials and auditors or their duly
authorized representatives may conduct required audits and examinations. The
Sub grantee further agrees that such officials, auditors or representatives shall have
access to any books, documents, papers and records of any recipients of this funding
and of any persons or entities which perform any activity which is reimbursed to any
extent with federal or state funds distributed under the authority of the Fiscal Year
2004 Homeland Security Appropriations Act and this Agreement.
7. Subgrantee shall complete and submit reports as requested by GEMA and cooperate
and assist GEMA in complying with ODP's tracking and reporting requirements.
Specifically, without limitation, Subgrantee shall:
(a) Submit updated information as requested by GEMA to assist the state in
completing the Initial Strategy Implementation Spending Plan to show how the
grant funds have been expended and how the funds will support the goals and
objectives outlined in the State's Homeland Security Strategy.
(b) Submit information at GEMA's request and direction to assist GEMA in
submitting Biannual Strategy Implementation Reports and Categorical
Assistance Program Reports in accordance with ODP's requirements as outlined
in the ODP Guide (Exhibit B).
2
8. Subgrantee agrees to comply with all applicable terms and conditions of the ODP
Guide (Exhibit B), which includes the requirements to:
(a) Institutionalize the use of the incident command system (ICS), as taught by the
United States Department of Homeland Security (US DHS), by the end of the
grant's two-year performance period.
(b) Adopt the National Incident Management System (NIMS) as mandated by the
Homeland Security Presidential Directive 5 (HSPD-5), beginning no later than
fiscal year 2005. ODP suggests that subgrantees begin utilizing NIMS
. concepts, principles, terminology, and technologies as they are made available
by the US DHS.
(c) Adhere to the State's Homeland Security Strategy.
(d) Sign and comply with the terms and conditions of GEMA's Statewide Mutual
Aid and Assistance Agreement and sign any other Mutual Aid Agreements
GEMA or ODP shall deem necessary to fulfill the Subgrantee's obligations
under this Agreement to render mutual aid for a suspected or real attack or in
the case of a weapons of mass destruction event.
9. The Sub grantee agrees that all purchases and expenditures authorized under this
program will be completed by June 27, 2008.
10. Payments to the Subgrantee will be made only upon presentation of the approved
Payment Request Form (Exhibit E). Reimbursements from invoices and applicable
canceled checks (or other justifying documentation) will only be made for eligible
equipment, materials, expenses and costs upon approval of the Program Manager.
Noncompliance by Subgrantee with the terms or conditions of this agreement will
constitute justification for non-payment of any amounts submitted on the Payment
Request Forms.
11. There shall be no changes to this Agreement unless mutually agreed upon by both
parties to the Agreement.
12. Termination. This agreement may be terminated for the following reasons:
Cause/Default. This agreement may be terminated for cause, in whole or in part, at
any time by the State for failure of the Sub grantee to perform any of the provisions or
to comply with a~y terms and conditions herein. If the State exercises its right to
terminate this agreement under the provisions of this paragraph, the termination shall
be accomplished in writing and specify the reason and termination date. The
Subgrantee will be required to submit the final invoice not later than 30 days after the
effective date of written notice of termination. Upon termination of this agreement,
the State shall not incur any new obligations after the effective date of the termination
and shall cancel as many outstanding obligations as possible. The above remedies are
in addition to any other remedies provided by law or the terms of this agreement.
3
Convenience. This agreement may be cancelled or terminated by either of the parties
without cause; however, the party seeking to terminate or cancel this agreement must
give written notice of its intention to do so to the other party at least 30 days prior to
the effective date of cancellation or termination.
Non-Availability of Funding. Notwithstanding any other provision of this agreement,
in the event that either of the sources of reimbursement for services under this
agreement (appropriations from the General Assembly of the State of Georgia or the
Congress of the United States of America) no longer exist or in the event the sum of
all obligations of GEMA incurred under this and all other agreements entered into for
this program exceeds the balance of such agreement sources, then this agreement
shall immediately terminate without further obligation of GEMA as of that moment.
The certification by the Director of GEMA of the occurrence of either of the events
stated above shall be conclusive.
13. Sub grantee will follow procurement standards as stated in the Financial Guide.
Subgrantee's name and mailing address: Augusta-Richmond County Emergency
Management Agency, 911 4th Street, Augusta, Georgia 30901.
14. GEMA's mailing address: Georgia Emergency Management Agency, P.O. Box
18055, Atlanta, Georgia 30316-0055.
AGREED:
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SUbgrrntee'l AuthOrized Official
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Signature Date
By:
17Avj::" 1> ~. C6 Fe; vi 1-114 ~ "-
Printed or Typed Name of Subgrantee's
Authorized Official
AG~
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Exhibit E
EXHIBIT E
Date:
Georgia Emergency Management Agency
State Homeland Security Grant Program
Payment Request Form
Instructions: All requests for payments must be supported by documentation supporting actual expenditures, Itemize each
. expenditure below to the fullest detail possible. Attach documentation that supports this payment request, such as copies of bills of
sale, invoices, receipts, and canceled checks evidencing payment. Do not send originals. Attach a continuation sheet if necessary.
* Please refer to Budget Worksheet for information needed in the following section *
Budget Worksheet Number:
Name of Jurisdiction:
GAN Number:
FIPs Number:
Area:
Item Number
From Budget
Worksheet
Requested Item to be Reimbursed
Requested
Quantity
Requested Cost
Description of Documentation
Attached in Support of this
Pa ent Ruest
Under penalty of peIjury, I certify that to the best of my lmowledge and belief the data above are correct and that all outlays were made
in . accordance with the grant conditions or other agreements, comply with procurement regulations contained within the Financial
Guide, and that payment is due and has not been previously requested. I understand that any part of this payment request that is not
supported by cost documents and/or expended within the scope of the approved project will be refunded to the State of Georgia within
30 days of receiving the deobligation notice.
Signature of Subgrantee' s Authorized Representative
Printed Name
Contact Phone Number
. !
.: Exhibit F .
ASSURANCES
OMB APPROVAL NO. Jl2.1'()140
The Applicant hereby assures and certifies compliance with all Federal statutes, regulations, policies, guidelines and requirements, including OMB
Circulars No. A-21, A-87, A-1l0, A-122, A-133; B.O. 12372 and Uniform Administrative Requirements for Grants and Cooperative Agreements
28 CPR, Part 66, Common rule, that govern the application, acceptance and use of Federal funds for this federally-assisted project. Also the
Applicant assures and certifies that:
1. It possesses legal authority to apply for the grant; that a resolution, motion or I o.
similar action has been duly adopted or passed as an official act of the applicant's
governing body, authorizing the filing of the application, including all
understandings and assurances containedtherein, and directing and authorizing
the person identified as the official representative of the applicant to act in
connection with the application and toprovide such additional information may
be required.
2.
It wiD comply with requirements of the provisions of the Uniform Relocation
Assistance and Real Property Acquisitions Act of 1970 (p.L. 91-646) which
provides for fair and equitable treatment of persons displaced as a result of
Federal and federally - assisted programs.
11.
It will comply with provisions of Federal law which limit certain political
activities of employees of a State or local unit of government whose principal
employment is in connection with an activity fmanced in whole or in part by
Federal grants. (5 USC 1501, etseq.)
3.
4.
It will comply with the minimum wage and maximum hours provisions of the
Federal Fair Labor Standards Act if applicable. .
12.
It will establish safeguards to prohibit employees from using their positions for a
purpose that is or gives the appearance of being motivated by a desire for private
gain for themselves or others, particularly those with whom they have family,
business, or other ties.
5.
6.
It will give the sponsoring agency or the Comptroller General, through any
authorized representative, access toand the right to examine all records, books,
papers, or documents related to the grant
7.
It wiD comply with all requirements imposed by the Federal sponsoring agency
concerning special requirements of law, program requirements, and o.ther 13.
administrative requirements. .
8.
It will insure that the facilities under its ownership, lease or supervision which
shall be utilized in the accOmplishment of the project are not listed on the
Environmental Protection Agency's (EP A)list of Violating Facilities and that it
will notifY the Federal grantor agency of the receipt of any communication from
the Directorofthe EPA OfficeofFedeial Activities indicating thatafacilitr to be
used in the project is under consideration for listing by the EP A.
It wiD comply with the flood insurance purchase requirements of Section 102( a)
of the Flood Disaster Protection Act of 1973, Public Law 93-234, 87 Stat 975,14.
approved December 31, 1976, Section 102(a) requires, on and after March 2,
1975; the purchase of flood insurance m communities where such insurance is
available as a condition for the receipt of any Federal financial assistance for
construction or acquisition purposes for usein any area that has been identified
by the Secretary of the Department of Housing and Urban Development as an
area having special flood hazards. The phrase "Federal financial assistance" 15.
includes any form ofloan, grant, guaranty, insurancepayment, rebate, subsidy,
disaster assistance loan or grant, or any other form of direct or indirect Federal
assistance. 16.
9.
Signature UL~-4 - Y
A /111
---'
It will assist the Federal grantor agency in its compliance with Section 106 of
the National Historic Preservation Act of 1966 as amended (16 USC 470),
Executive Order 11593, and the Archeological and Historical Preservation Act
of 1966 (16 USC 569 a-I et seq.) by (a) consulting with the State Historic
Preservation Officer on the conduct of investigations, as necessary, to identifY
properties listed in or eligible for inclusion iri the National Register of Historic
Places that are subject to adverse effects (see 36 CPR Part 800.8) by the
activity, and notifYing the Federal grantor agency of the existence of any such
properties, and by (b) complying with ail requirements established by the .
Federal grantor agency to avoid or mitigate adverse effects upon such
properties.
It will comply, and assure the compliance of all its subgrantees and
contractors, with the applicable provisions of Title I of the Omnibus Crime
Control and Safe Streets Act of 1968, as amended, the Juvenile Justice and
Delinquency Prevention Act, or the Victims of Crime Act, as appropriate; the
provisions of the current edition of the Office of Justice Programs Financial
and Administrative Guide for Grants, M71 00.1; and all other applicable
Federal laws, orders, cireulars, or regulations.
It will comply with the provisions of28 CFR applicable to grants and
cooperative agreements including Part 18, Administrative Review Procedure;
Part 20, Criminal Justice Information Systems; Part 22, Confidentiality of
IdentifIable Resesrch and Statistical Information; Part 23, Criminal
Intelligence Systems Operating Policies; Part 30, Intergove-rrimental Review
of Department of Justice Programs and Activities; Part 42,
NondiscriminationlEqual Employment Opportunitr Policies and Procedures;
Part 61, Procedures for Implementing the National Environmental Policy Act;
Part 63, Floodplain Management and Wetland Protection Procedures; and
Federal laws or regulations applicable to Federal Assistance Programs.
It will comply, and all its contractors will comply, with the nondiscri-mination
requirements of the Omnibus Crime Control and Safe Streets Act of 1968, as
amended, 42 use 3789(d), or Victims of Crime Act
(as appropriate); Title VI of the Civil Rights Act of 1964, as amended;
Section 504 of the Rehabilitation Act of 1973, as amended; Subtitle A, Title II
of the Americans with Disabilities Act (ADA) (1990); Title IX
of the Education Amendments of 1972; the Age Discrimination Act of 1975;
Department of Justice Non-Discrimination Regulations, 28 CPR Part 42,
Subparts C, D, E, and G; and Department of Justice regulations on disability
discrimination, 28 CFR Part 35 and Part 39.
In the event a Federal or State court or Federal or State administrative agency
makes a finding of discrimination after a due process hearing on the grounds of
race, cOlor, religion, national origin, sex, or disability against a recipient of
funds, the recipient will forward a copy of the rmding to the Office for Civil
Rights, Office of Justice Programs.
It will provide an Equal Employment Opportunity Program if required to
maintain one, where the application is for ~500,000 or more.
It will comply with the provisions of the Coastal Barrier Resourees Act (p.L.
97-348) dated October I 9, 1982 (16 USC 3501 et seq.) which prohibits the
expenQiture of most new Federal funds within the units of the Coastal Barrier
Resources System.
5:> (Z?r {~
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Exhibit G
, ..
U,S. Df;PARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
OFFICE OF THE COMPTROLLER
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
OlHER RESPONSIBIUTY MAITERS; AND DRUG-FREE WORKPLACEREQUIREMENrs
Applicants should refer to the reg'ulatlons 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
form. SIgnature of thIs form provides fOf compliance with certification requlre~ents under 28 CFR Part 69, -New
Restrictions on Lobbying- an9 28 CFR Part 67, -GQvernment-wlde Debarment and Suspens!on (Nonpro-curement) and
Govemm~nt-wlde RequIrements for Drug-Free Workplace (Grants)." The certifications shall be treated as a materIal
representatIon of fact upon which reliance will be placed when the Department of Justice determines to award the
oovered transact/on, grant, or coopera(lve agreement. ..
1. LOBBYING
,
A.$ required by Section 1352, Title 31 of the U.S. CQde, and
Implemented at 28 .CFR Part 69, for persons entering Into a
grant or cooperative agreement over $100,000, as defined at
28 CFR Part 69, the applicant cerUfles that:
(a).No Federal appropriated funds have been paid or will be
paId, by or on' behalf of the undersigned, to any person for In-
fluencIng or attempUng to Influence an officer or employee of any
agency,' a Member. of Congr6S1!, an officer or employee of
Congress, or an employee of a MelT!ber of Congress In con-
ne<ltIon wtth the making of any Federal grant, the entering Into
of any cooperative agreement, and the extension, conl/nuatlon,
re~wal, amendment, or modification of any Federal grant or
cooperative 'agreement;
. .(b) If any funds other ttlan Federal appropriated funds have
been paid or will be paid to any person for InfluencIng or at-
tempOng to ~nftuencean officer or employee of any agency, a
Member of COngress, 8,n officer or employee 'of Congress. or
an employee of a Member of Congress In connection with thIs
. Federal grant or COoperatiVe agreement, the undersigned shall
COmplete and submit Standard Form - LLL, .Olsolosure of
Lobbying Actlv/Ues: In acoordanoe wIth Its Instructions;
(e) The undersigned shaU require that the larigu~e of th.1s cer-
tification be Included mthe award documents for all subawards
at aU tlenl (IncludIng subgrants, contraots under 'grants al'!d
cooperative at1f'Gements, and subcontracts) and that aU SUb-
recipients shaD certify and dIsclose aCCOrdingly.
. .
2. DEBARMENT, SUSPENSION, ANP OTHER
RESPONSIB/U1Y MAneRS
(DIRECT RECIPIENT)
As requIred by Exeoutlve Order 12549,Debarment and
Suspension, and Implemented at 28 CFR Part 67, 'for prospec-
tive partiCipants In primary covered transactions. as defined at
28 CFR Part 67, Section 67.510-
A. The applicant certifies that It and Its prInCipals:
(a) Are not pr_sently debarred, 8ullPended, proposed for debar-
ment, declared 'nellglble, sentenced to a denial of Federal
benefits by a State or Federal court, or voluntarily excluded
from covered transactions by any Federal department
or agency;
(b) Have not withIn a three-year perIod preceding this applica-
tion bee" convlQted of or had a olvll Judgm~nt rendered against
them for commission of fraud ot a criminal offense In. conneo.
Uon wIth obtaining, attempting to obtaIn, or performing a
publlo (Federal, State, or local) transaction or contract under a
pUblic: transaction; violation of Federal or State antitrust statutes
or commission. of embezzlement, theft, forgery,
brfbery, falsification or destnJoOon of records, makIng false
statements,or re~lvlng s~olen property;
(c) Are not .presently Indicted' for or otherwIse crimInally or
ciVilly charged by a governmental entity (Federal, State, or
10caQ with con1mlsslon of any of the offenses enumerated In
paragraph (1)(b) 'of this certlflcatlon;"and
(d) Have not within a three-year periOd preoodtng thIs applica-
tion had one or more pubQo transacUons (Federal, State, or
IocaQ termInated for cause or default; and
B. Where the applicant Is unable to cerUfy to any of the
statements In this certlfIcaUon, he or she shall attach an
explanation to this application.
3. DRUG-FREE WORKPLACE
(GRANTEES OntER 1liAN INDIVIDUALs)
h required by the Drug-Free Worf<place Act of 1968, and .
Implemented at 28 <?FR Part 67, Subpart Fe for grantees, as
defined aU8 CFR Part 87 Sections 67.615 and 67_~
A. The appDcant certlftes that It will or WRl. continue to provlde
a drug-free workplace by: . . .
(a) PUblishing a statement notIfying employees that the
unlaWful manufacture, distribution, dispensing, possess/on, or
use of a controlled substance Is prohibited In the grantee's
workplace and specifying the actions that will be taken against
employees for vlolaOon of such Prohlbltl~ .
(b) establishing an on-golng drug..free awareness program to
Inform employees about-
(1) .The dangers of drug abuse In the workplace;
(2) The grantee's polloy of maintaining a drug-free workplace;
(3) Any.avallable drug counseling, rehabllltatlon, and employee.
assistance programs; and
(4) The penalties that may be Imposed upon employees for
drug abUse violations OCCUtrlng In the workplace; .
(0) Making It a requirement that each employee to be engaged
In /he performance olthe grant be given a copy of /he Jtate- .
ment required by paragraph (8);
(d) Notifying the employee In the statement required by para-
graph (a) thai, as a condition of employment under the grant,
the employee will-
01' ~M ~11e (3091) REPLACES OJP ,"ORMS ~06112. Ml61f3 ANO""oe1/~ WHICH ARE OBSOLETe.
(1) Abide by the terms of the statement; and
(2) Notlfy the employer In wrrtlng of his or her oonvlotlon for a
violation of a orlmlnal drug statute ooourri"g In Iheworkplace
no later than fl,ve oalendar days after such oonvIctlon;
(e) Notifying the agency, In. writIng, within 10 calendar days
after receiving notice under SUbparagraph (d)(2) from an
employee or otherwise receiving actual notice of such conv/o-tlon.
Employers of convicted employees must provide notloe,lne/ud/ng
pOSition title, to: Department of Justice, Office of' .
Jusllce Programs, ATTN: Control Desk, 633 Indiana Avenue.
N.W., Washington, D.C. 20531. Notice shalllne/ude th~ Iden-
tification numb~r(s) of each affected gmnt
(t) Taklng one of the following actions. within 30 celendar
daYs ,of r.ecelvlng notice under subparagraph (d)(2), wlth .
respect to any emplOyee who Is so oonv/cted-
(i) Taking appropriate peraonnel aotlon against such an .'
employee, up to and Including termJnatlon, consistent wlth the
requirements of the Rehabilitation Act of 1973, as amendea; or
(2) Requiring such employee to partlolpate satisfactorily In 8
drug abuse assistance or rehabUltatlon progmm apJ1roved for
such purposes by 8. Fedeml, State. or local health, law enforce-
ment, 'or other appropriate a~enoy;
(g) Making a good ft!1th effort to continue to maintain a drug-
free workplace through Implementatlon.of pamgraphs (a), (b),
(e), (d), (e), and (t).
B. The grantee may Insert In the space Provided beloW the
slte(s) for the performance of work done In connection with
the speolflc grant
Place of PerformanCe (Street address, city; county, state, zip
code)
Check O'1f there are workplaces on file that are not Indent/fled
here.
Seollon 67, 630 of the regulations provides that a grantee that
Is a 'State may elect to make one certification In eaoh Federal
fiscal year. A oOPY of which should be Included with each ap-
plication for Department of Justice funding. States and State
agenoles may elect to use OJP Form 4061/7.
,
CheQk 0 If the State hl1s elected to complete OJP Form
4061n.
DRUG-FREE WORKPLACE
(GRANTEES WHO AftE INDMDUALS)
As required by the Drug-Free Workplace Act of 1988. and
Implemented at 28 CFR Part 67, Subpart F, for gmntees, as
defined at 28 CFR Part 67; Sections 67.615 and 67.620-
A.. As a condition of the grant, I certify that I wlil not.engage
In the unlawfut manufacture, distribution, dispensIng, posses-
sion, or use of a controlled substance In conduotlng allY
activity with the grant; and .
B. If convlcted of a ortmlnal dr\lg offense resulting from 8
violation ooourrlng during the conduct of any grant activity, I
will report the conviction, In writing, wIthin 10 calendar d8y$,
of the convlotlon, to: Department of Justice, OffIce of Justice
Progran1S. ATTN: Control Des1<.' 633 tndi~08 Avenue, N.W..
Was,hlngton. D.C. 20531.
As the duly authorized representative of the applicant, I hereby certify that the applk:ant will comply with the above certifications.
1. G~ntee Name and Address:
2. Application NU!l1ber and/or Project Name.
3. Grantee IRSNendor Number
4. l)'ped Name and TItle of Authorized RepresentatIve
~v ~6f4 g---
r I--- 5. SIgnature . .
-s ('Sot DO
6. Date
4t?PPf
'U.s. OoYemment Prln81lCJ 0IIlQ8: 1998 -405-03Tf.4001<l