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<br /> f) Taking one of the following actions,within 30 with the awarding of any Federal contract,the
<br /> calendar days of receiving notice under paragraph making of any Federal grant,the making of any
<br /> (d)(2),with respect to any employee who is so Federal loan,the entering into of any cooperative
<br /> convicted— agreement, and the extension, continuation,renewal,
<br /> (1)Taking appropriate personnel action against such amendment, or modification of any Federal contract,
<br /> an employee,up to and including termination, grant, loan, or cooperative agreement.
<br /> consistent with the requirements of the
<br /> Rehabilitation Act of 1973,as amended; or (2) If any funds other than Federally appropriated funds
<br /> (2)Requiring such employee to participate have been paid or will be paid to any person for
<br /> satisfactorily in a drug abuse assistance or influencing or attempting to influence an officer or
<br /> rehabilitation program approved for such employee of any agency, a Member of Congress,an
<br /> purposes by a Federal, State,or local health, law officer or employee of Congress, or an employee of
<br /> enforcement, or other appropriate agency; a Member of Congress in connection with this
<br /> Federal contract, grant, loan,or cooperative
<br /> g) Making a good faith effort to continue to maintain a agreement,the undersigned shall complete and
<br /> drug-free workplace through implementation of submit Standard Form-LLL, "Disclosure of
<br /> paragraphs(a), (b), (c),(d),(e), and(f). Lobbying Activities," in accordance with its
<br /> instructions.(If needed, Standard Form-LLL,
<br /> For purposes of paragraph(e)regarding agency "Disclosure of Lobbying Activities," its instructions,
<br /> notification of criminal drug convictions, the DOH has and continuation sheet are included at the end of this
<br /> designated the following central point for receipt of such application form.)
<br /> notices:
<br /> (3) The undersigned shall require that thelanguage of
<br /> Compliance and Internal Control Officer this certification be included in the award documents
<br /> Office of Grants Management for all subcontracts at all tiers(including
<br /> WA State Department of Health subcontracts, subcontracts,and contracts under
<br /> PO Box 47905 grants, loans and cooperative agreements)and that
<br /> Olympia, WA 98504-7905 all subrecipients shall certify and disclose
<br /> accordingly.
<br /> 3. CERTIFICATION REGARDING LOBBYING
<br /> This certification is a material representation of fact upon which
<br /> Title 31, United States Code, Section 1352,entitled reliance was placed when this transaction was made or entered
<br /> "Limitation on use of appropriated funds to influence into.Submission of this certification is a prerequisite for making
<br /> certain Federal contracting and financial transactions," or entering into this transaction imposed by Section 1352, U.S.
<br /> generally prohibits recipients of Federal grants and Code. Any person who fails to file the required certification
<br /> cooperative agreements from using Federal shall be subject to a civil penalty of not less than $10,000 and
<br /> not more than$100,000 for each such failure.
<br /> (appropriated) funds for lobbying the Executive or
<br /> Legislative Branches of the Federal Government in 4. CERTIFICATION REGARDING PROGRAM
<br /> connection with a SPECIFIC grant or cooperative FRAUD CIVIL REMEDIES ACT (PFCRA)
<br /> agreement. Section 1352 also requires that each person
<br /> who requests or receives a Federal grant or cooperative The undersigned(authorized official signing for the
<br /> agreement must disclose lobbying undertaken with non- contracting organization)certifies that the statements
<br /> Federal(nonappropriated)funds. These requirements herein are true, complete, and accurate to the best of his
<br /> apply to grants and cooperative agreements or her knowledge, and that he or she is aware that any
<br /> EXCEEDING $100,000 in total costs (45 CFR Part 93). false, fictitious,or fraudulent statements or claims may
<br /> subject him or her to criminal, civil, or administrative
<br /> The undersigned(authorized official signing for the penalties. The undersigned agrees that the contracting
<br /> contracting organization)certifies,to the best of his or organization will comply with the Public Health Service
<br /> her knowledge and belief,that: terms and conditions of award if a contract is awarded.
<br /> (1) No Federal appropriated funds have been paid or 5. CERTIFICATION REGARDING
<br /> will be paid,by or on behalf of the undersigned,to ENVIRONMENTAL TOBACCO SMOKE
<br /> any person for influencing or attempting to influence
<br /> an officer or employee of any agency, a Member of Public Law 103-227, also known as the Pro-Children
<br /> Congress, an officer or employee of Congress,or an Act of 1994(Act),requires that smoking not be
<br /> employee of a Member of Cg7ress in connection
<br /> DOH Contract#N13413 // Page 9 of 13 rev. 4/28/04
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