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.
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
(c) The undersigned shall require that the language of this
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.
As required by Executive Order 12549, Debarment and
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;
(c) Are not presently indicted for or otherwise criminally or
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.
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
(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
U.S. Election Assistance Commission
U.S. Election Assistance Commission
3) Any available drug counseling, rehabilitation, and
assistance programs; and
(4) The penalties that may be imposed upon employees
for drug abuse violations occurring in the workplace;
(c) Making it a requirement that each employee to be
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
(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
1. Grantee Name and Address:
2. Typed Name and Title of Authorized Representative:
3. Signature:
4. Date