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U.S. ELECTION ASSISTANCE COMMISSION

DIVISION OF GRANTS

CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION

AND OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE

All recipients of Federal financial assistance from the Election Assistance Commission (EAC) must complete and sign this form

before EAC will disburse funds. Signature of this form provides for compliance with Federal certification requirements for New

Restrictions on Lobbying, “Government-wide Debarment and Suspension (Non-procurement) and Government-wide

Requirements for Drug-Free Workplace.

1. LOBBYING

As required by Section 1352, Title 31 of the U.S. Code,

the recipient certifies that:

(a) No Federal appropriated funds have been paid or will

be paid, by or on behalf of the undersigned, 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 the making of any

Federal grant, the entering into of any cooperative

agreement, and the extension, continuation, renewal,

amendment, or modification of any Federal grant or

cooperative agreement;

(b) 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 grant

or cooperative agreement, the undersigned shall complete

and submit Standard Form - LLL, “Disclosure of Lobbying

Activities.”

certification be included in the award documents for all

subawards at all tiers (including subgrants, contracts

under grants and cooperative agreements, and

subcontracts) and that all subrecipients shall certify and

disclose accordingly.

2. DEBARMENT, SUSPENSION, AND OTHER

RESPONSIBILITY MATTERS

(DIRECT RECIPIENT)

As required by Executive Order 12549, Debarment and

Suspension—

A. The recipient certifies that it and its principals:

(a) Are not presently debarred, suspended, proposed for

debarment, declared ineligible, 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

application 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 statutes or commission of

embezzlement, theft, forgery, bribery, falsification or

destruction of records, making false statements, or

receiving stolen property;

civilly charged by a governmental entity (Federal, State, or

local) with commission of any of the offenses enumerated

in paragraph (1)(b) of this certification; and

(d) Have not within a three-year period preceding this

application had one or more public transactions (Federal,

State, or local) terminated for cause or default; and

B. Where the applicant is unable to certify to any of the

statements in this certification, he or she shall attach an

explanation to this certification.

3. DRUG-FREE WORKPLACE

As required by the Drug-Free Workplace Act of 1988—

A. The recipient certifies that it will or will continue to

provide a drug-free workplace by:

(a) Publishing a statement notifying employees that the

unlawful manufacture, distribution, dispensing,

possession, or use of a controlled substance is prohibited

in the grantee’s workplace and specifying the actions that

will be taken against employees for violation of such

prohibition;

(b) Establishing an on-going drug-free awareness program

to inform employees about—

(1) The dangers of drug abuse in the workplace;

(2) The grantee’s policy of maintaining a drug-free

workplace;

U.S. Election Assistance Commission

(

3) Any available drug counseling, rehabilitation, and

employee

assistance programs; and

(4) The penalties that may be imposed upon employees

for drug abuse violations occurring in the workplace;

engaged in the performance of the grant be given a copy

of the statement required by paragraph (a);

(d) Notifying the employee in the statement required by

paragraph (a) that, as a condition of employment under

the grant, the employee will:

(1) Abide by the terms of the statement; and

(2) Notify the employer in writing of his or her conviction

for a violation of a criminal drug statute occurring in the

workplace no later than five calendar days after such

conviction;

(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

conviction. Employers of convicted employees must

provide notice, including; position title, to: EAC, ATTN.

Director of Grants, 1225 New York Avenue, N.W., Suite

1100 Washington, D.C. 20005. Notice shall include the

identification number(s) of each affected grant;

(f) Taking one of the following actions, within 30 calendar

days of receiving notice under subparagraph (d)(2), with

respect to any employee who is so convicted—

(1) Taking appropriate personnel action against such an

employee, up to and including termination, consistent

with the requirements of the Rehabilitation Act of 1973,

as amended; or

(2) Requiring such employee to participate satisfactorily

in a drug abuse assistance or rehabilitation program

approved for such purposes by a Federal, State, or local

health, law enforcement, or other appropriate agency;

(g) Making a good faith effort to continue to maintain a

drugfree workplace through implementation of paragraphs

(a), (b), (c), (d), (e), and (f).

B. The grantee may insert in the space provided below the

site(s) for the performance of work done in connection with

the specific grant:

Place of Performance: Street address, city, state, zip code

As the duly authorized representative of the State, I hereby certify that the recipient will comply with the above

requirements.

1. Grantee Name and Address:

2. Typed Name and Title of Authorized Representative:

3. Signature:

4. Date

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CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY (Election Assistance Commission)

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