HomeMy WebLinkAbout20042529.tiff RESOLUTION
RE: APPROVE APPLICATION FOR FEDERAL ASSISTANCE FOR BASIC MIGRANT AND
SEASONAL TECHNICAL ASSISTANCE ONE TIME FUNDING AND AUTHORIZE CHAIR
TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with an Application for Federal Assistance for
Basic Migrant and Seasonal Technical Assistance One Time Funding between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf
of the Department of Human Services, Family Educational Network of Weld County,commencing
January 1,2004,and ending December 31,2004,with further terms and conditions being as stated
in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application,a copy
of which is attached hereto and incorporated herein by reference.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Application for Federal Assistance for Basic Migrant and Seasonal
Technical Assistance One Time Funding between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Human Services, Family Educational Network of Weld County, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 23rd day of August, A.D., 2004, nunc pro tunc August 18, 2004.
BOARD OF COUNTY COMMISSIONERS
W D COUNTY, COLORADO
1 , X444 s8" b,
tp,. Robert D. Masden, Chair
' Igo I('ea.4 Jerk to the Board -)C
William H. Je e, Pro-Tem
/ +'Clerk to the Board
= M. J. 'le
APP AS TO .
David . Long
unty At or ey
Glenn Vaad
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2004-2529 Date of signature:
c. 0 , H ( J HR0075
l I O9 -coz-Oc/
MEMORANDUM
a
fDATE: August 193, 2004
TO:
Board of County Commissioners
will C. FROM: Walt Speckman, Executive Director
COLORADO SUBJECT: Technical Assistance
Enclosed for Board approval is an application for one time funding for Technical Assistance for
Curriculum Development through the Basic Migrant and Seasonal Head Start Basic Grant.
FENWC is requesting $15,348.62 from the PY2004 — Migrant and Seasonal Basic Head Start
Grant Application.
The purpose of this one time funding is to improve Program Services to families and children.
If you have any questions please contact Janet Flaugher, Director, @ 353-3800, ext. 3340.
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2004-2529
APPLICATION FOR OMB Approval No.0348-0043
2.DATE SUeM
FEDERAL ASSISTANCE SUBMITTED Applicant Identifier
90CM0136
,
t. TYPE OPEUaWSSIOIt 3.DATE RECEIVED BY STATE State Application Identifier
Application Preapplicatlon
❑ Construction O Construction
4.DATE RECEIVED BY FEDERAL AGENCY Federal Identifier
❑ Non-Construction O Non-Construction 90CM0136
S. APPLICANT INFORMATION
Legal Marne Weld County Division of Human Serv. Organizational Unit:
Family Educational Network of Weld County
Address(give city,county,state.and zip code): Name and telephone number of the person to be contacted on matters involving
15551 N. 17th Avenue this application (give area code)
P.O. Box 1805 Walt Speckman 970-353-3800
Greeley, CO 80632 Weld Executive Director, WCDHS
4 EMPLOYER IDENTIFICATION NUMBER(EINI: 7. TYPE OF APPLICANT:(enter appropriate letter in box) BB
8 4 6 0 0 0 8 1 3 A. State H.Independent School Dist.
B. County I. State Controlled Institution of Higher Learning
S TYPE OF APPLICATION: C. Municipal J. Private University
D. Township K. Indian Tribe
O New O Continuation d Revision E. Interstate L. Individual
F. Intermunicipal M.Profit Organization
If Revision,enter appropriate letter(s)in box(es): ® ❑ G.Special District N.Other(Specify):
A. Increase Award 8.Decrease Award C.Increase Duration
D. Decrease Duration Other(specify): S NAME OF FEDERAL AGENCY:
USDHHS/ACY/ACYF/Migrant Branch
le. CATALOGIOFF FUMB FEDERALDOMESTIC 9 3 • 6 0 D I1. DESCRIPTIVE TITLE OF APPLICANTS PROJECT:
ASSISTACPY2004
TITLE Head Start Basic Migrant and Seasonal Grant Application
Technical Assistance One-Time Funding
I2. AREAS AFFECTED BY PROJECT(cities,counties,states.etc.):
State-wide Colorado
ti PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICTS OF:
Start Date Ending Date a.Applicant b.Project
1/01/04 12/31/04 4
tt ESTIMATED FUNDING: M.IS APPLICATOR SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?
a Federal $15,348.62 .0o a. YES. THIS PREAPPLICATIOWAPPLICATION WAS MADE AVAILABLE TO THE
STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
b. Applicant $ 3,069.00 .00 DATE
a State S • .00
b NO. O PROGRAM IS NOT COVERED BY E.O. 12372
d. Local $ .00
® OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
a Other $ .00
t. Program Income $ .00 17. IS THE APPLICANT DEUNOUENT ON ANY FEDERAL DEBT'?
q.TOTAL El YesYes If"Yes;"attach an explanation. No
$18,348.62 .00
II.TO THE BEST OP MY KNOWLEDGE AND BELIEF.ALL DATA IN THIS APPLICATON/PREAPPLICATION ARE TRUE AND CORRECT.THE DOCUMENT HAS BEEN DULY
AUTHORIZED BY TIE GOVERNING BODY OF THE APPLICANT AND THE APPUCANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED
a.Typed Name of Authorized Representative b Title c. Telephone number
Robert D. Masden Chair, Weld Co. Board of (970) 356-4000
d. Signature of Authorized Representative (� (� , ,, commissioners e. Date Signed
\\V \/ f`r\T-\J\llr ►gV1Ir`1M-IC'/l\I,/ AUG 2 3 LOU*?
Previous Editions Not Usable 'C^ Standard Form 424 (REV 4-88)
Prescribed by OMB Circular A-102
Authorized for Local Reproduction 7
riot
DEPARTMENT OF HUMAN SERVICES
Family Educational Network of Weld County
I1551 NORTH 17TH AVENUE
WI D PO BOX 1805
C. GREELEY, CO 80632
(9 O)353-3800
FAX(970)356-3975
COLORADO
Family Educational Network of Weld County
Migrant and Seasonal Head Start Program
90-CM-0136
ONE-TIME FUNDING
RESPONDING TO TRAINING AND TECHNICAL ASSISTANCE NEEDS
PROPOSAL NARRATIVE
The Family Educational Network of Weld County, Migrant and Seasonal Head Start
Program, is requesting funding for Training and Technical Assistance to respond to
identified training needs to benefit services to children and families. Based on the
program self-assessment, monthly program monitoring, community assessment data
and our 2003 Federal PRISM Review, we have developed a framework for our agency's
Training and Technical Assistance Plan.
One component of that framework is the revamping of the program's curriculum and
curriculum delivery system, including the articulation of child outcomes. In our Infant
and Toddler classrooms we have adopted the Creative Curriculum and the Ounce Scale
Observational Tool and have successfully implemented them during the current
program year. As we continue to develop this area, we are continuing the curriculum
adoption process for our preschool program. Our goals for this area are:
1) to improve program staff's understanding of what constitutes a
curriculum and its role in the structure of the preschool classroom.
2) to increase program staff's understanding and knowledge of Creative
Curriculum as the base component of a program-wide curricular model.
3) to increase program staff's understanding and skills in the utilization of the
Creative Curriculum continuum and the Creative Curriculum Port (electronic
outcomes tracking format) for child assessment and tracking of child
progress, including developing basic individual skills in the use of technology
with a variety of programs (Creative Curriculum Port, ChildPlus, Microsoft
Word, etc.) as a support system for the curricular component.
4) To increase program staff's knowledge and understanding of how to use data
as a took to develop and/or modify lesson plans, and child goals and
objectives.
5) To increase program staff's knowledge and understanding or how data can
be used to evaluate children's progress, to make decisions on curriculum
delivery, to plan for children's needs, to identify professional development
training needs for staff, to develop and provide practical and valuable reports
to be shared with parents, governing entities and funding sources.
6) To increase parents' knowledge and understanding of how curriculum is used
in Head Start to foster their child's development.
7) To increase parents' knowledge and understanding of Creative Curriculum.
and of how their children's classroom experiences can be supported in the
home.
Initial Consultation
Initial Consultation with Creative Curriculum consultants will be conducted by the
Program's Education Specialist and Education Coordinators. The purpose of the initial
consultation will be to establish goals and objectives for the training to follow and to
determine how the training will fit into the long-range goals of the early childhood
education system (how it will interface into the systems approach to services).
Staff and Parent Training
The purpose of the training will be to introduce staff and parents to preschool Creative
Curriculum and its long-range systems implications for the program. In addition, it will
provide participants with the basic skills necessary to implement the curriculum.
Training for program staff and parent representatives on Creative Curriculum will be
conducted in 3 day-long sessions over the course of one week and involving staff from
the front range and western slope programs. Training on the use of computer systems
to support the curriculum will be conducted weekly for a period of 6 weeks.
Follow-Up Training
As curriculum is implemented, a first follow-up visit will be scheduled to monitor
progress, make adjustments as necessary and provide corrective training to education
staff in order to ensure the curriculum is being implemented effectively.
A second follow-up visit will focus on utilizing collected data in the planning process.
BUDGET NARRATIVE
Initial Consultation $2,035.00. The budgeted amount presented for this phase
includes the projected cost for consultant fee, round trip airfare, perdiem, rental car and
lodging.
Training and Materials $9,243.62 The budgeted amount presented for this phase
includes the projected cost of consultant fees round trip airfare, perdiem, rental car and
lodging, training materials for each participant, (50) and trainers guides to be used by
Education Component staff for ongoing follow-up training.
Follow-up visits $4,070.00 The budgeted amount presented for this phase included
the projected cost for consultant fee, round trip airfare, perdiem, rental car and lodging.
The budget presented is $15,348.62. FENWC would appreciate an award of any or all
of the amount being requested.
Project Budget
Item Individual'Coat Extended Total
Creative Curriculum
Consultant (initial) $1,500.00 1 day $1,500.00
Creative Curriculum
Consultant (training) $1,500.00 3 days $4,500.00
Creative Curriculum
Consultant Follow up $1,500.00 2 days $3,000.00
Visits
Consultant travel, $ 535.00
lodging, perdiem, rental $ 800.00 4 trips
car $ 535.00 (6 days) $2,405.00
$ 535.00
Technology Consultant $ 150.00 6 sessions $ 900.00
Training Materials
(Technology) $ 10.00 50 $ 500.00
Training Materials
(Creative Curriculum for $ 38.21 50 $1,910.50
Preschool)
Training Materials
(Creative Curriculum $ 22.36 3 $ 89.44
Trainers Guide)
Training Materials
(Creative Curriculum
Developmental
Assessment Toolkit $ 76.46 3 $ 229.38
(English)
Training Materials
(Creative Curriculum
Developmental
Assessment Toolkit $ 76.46 3 $ 229.38
(Spanish
Creative Curriculum
Progress and Outcomes
Report Tool $ 42.46 2 $ 84.92
Total $15,348.62
MATCH NARRATIVE
The Match of$3,000 will be covered by volunteer time documented by the Policy
Council and other parent representatives who will donate their time to participate in these
trainings. If any additional match is needed, it will be from local general revenue cash
donated to the project.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
COMPENDIUM OF REQUIRED CERTIFICATIONS AND ASSURANCES
SF 4248
ASSURANCES - NON-CONSTRUCTION PROGRAMS
Note: Certain of these assurances may not be applicable to your project or program. If you have
questions, please contact the awarding agency. Further, certain Federal awarding agencies may require
applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial
capability (including funds sufficient to pay the non-Federal share of project costs) to ensure proper
planning, management and completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the
State, through any authorized representative, access to and the right to examine all records, books,
papers, or documents related to the award; and will establish a proper accounting system in accordance
with generally accepted accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes
or presents the appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the
awarding agency.
5. Will comply with the intergovernmental Personnel Act of 1970 (42 U.S.C. 4278-4763) relating to
prescribed standards for merit systems for programs funded under one of the nineteen statutes or
regulations specified in Appendix A of OPM=s Standards for a Merit System of Personnel Administration
(5 CFR 900, Subpart F).
6. Will comply with all Federal statutes relating to non-discrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the bases of
race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended(20 U.S.C.
1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. 794), which prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to non-discrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse
and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating
to non-discrimination on the bases of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as amended, relating to confidentiality of the
alcohol and drug abuse patient records; (h) Title VII of the Civil Rights Act of 1968(42 U.S.C. 3601 et
seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (I) any other
non-discrimination provisions in the specific statute(s) under which application for Federal assistance is
being made; and(I) the requirements of any other non-discrimination statute(s) which may apply to the
application.
7. Will comply, or has already complies, with the requirements of Titles Il and III of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and
equitable treatment of persons displaced or whose property is acquired as a result of Federal or Federally
assisted programs. These requirements apply to all interests in real property acquired for project
purposes regardless of Federal participation in purchases.
8. Will comply with the provisions of the Hatch Act(5 U.S.C. 1501-1508 and 7324-7328) which limit the
political activities of employees whose principal employment activities are funded in whole or in part with
Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act(40 U.S.C. 276a to 276a-7), the
Copeland Act(40 U.S.C. 276c and 18 U.S.C. 874), and the Contract Work Hours and Safety Standards
Act (40 U.S.C. 327-333), regarding labor standards for Federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood
Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to
participate in the program and to purchase flood insurance if the total cost of insurable construction and
acquisition is $10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a)
institution of environmental quality control measures under the National Environmental Policy Act of 1969
(P.L. 91-190) and Executive Order(EO) 11514; (b) notification of violating facilities pursuant to EO 11738;
(c) protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in
accordance with EO 11988; (e) assurance of project consistency with the approved State management
program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. 1451 et seq.); (f)
conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear
Air Act of 1955, as amended(42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking
water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and(h) protection of
endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205)
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1271 et seq.) related to protecting
components or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic
Preservation Act of 1966, as amended(16 U.S.C. 470), EO 11593 (identification and protection of historic
properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research,
development, and related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131
et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research,
teaching, or other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.) which
prohibits the use of lead based paint in the construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the single
Audit Act of 1984.
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and
policies governing this program.
DRUG-FREE WORKPLACE REQUIREMENTS
GRANTEES OTHER THAN INDIVIDUALS
By signing and/or submitting this application or grant agreement, the grantee is providing the certification set
out below.
This certification is required by regulations implementing the Drug-Free Workplace Act of 1988, 45 CFR, Part
76, Subpart F. The regulations published in the January 31, 1989 Federal Register, require certification by
grantees that they will maintain a drug-free workplace. The certification set out below is a material
representation of fact upon which reliance will be placed when HHS determines to award the grant. False
certification or violation of the certification shall be grounds for suspension of payments, suspension or
termination of grants, or government-wide suspension or debarment.
Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If
known, they may be identified in the grant application. If the grantee does not identify the workplaces at the
time of application, or upon award, if there is no application, the grantee must keep the identity of the
workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify
all known workplaces constitutes a violation of the grantee's drug-free workplace requirements.
Workplace identifications must include the actual address of buildings (or parts of building) or other sites
where work under the grant takes place. Categorical descriptions may be used(e.g. all vehicles of a mass
transit authority of State highway department while in operation, State employees in each local unemployment
office, performers in concert halls or radio studios).
If the workplace identified to HHS changes during the performance of the grant, the grantee shall inform the
agency of the change(s), it previously identified the workplaces in question (see above).
Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free
Workplace common rule apply to this certification. Grantees'attention is called, in particular, to the following
definitions from these rules:
"Controlled substance"means a controlled substance in Schedules I through V of the Controlled Substances
Act (21 USC 812) and as further defined by regulations (21 CFR, 1308.11 through 1308.15). "Conviction"
means a finding of guilt(including a plea of nob contendere)or imposition of sentence, or both, by any judicial
body charged with the responsibility to determine violations of the Federal of State criminal drug statutes;
"Criminal drug statute"means a Federal or non-Federal criminal statute involving the manufacture, distribution,
dispensing use, or possession of any controlled substance; "Employee"means the employee of a grantee
directly engaged in the performance of work under a grant including: (i)All "direct charge"employees; (ii) all
"indirect charge"employees unless their impact of involvement is insignificant to the performance of the grant;
and(iii)temporary personnel and consultants who are directly engaged in the performance of work under the
grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of the
grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent
contractors not on the grantee's payroll; or employees of subrecipients or subcontractors in covered
workplaces).
The grantee certifies that it will 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 a 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;
(3) Any available drug counseling, rehabilitation, employee 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 be 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 of any criminal drug statute conviction for a violation occurring in
the workplace no later than five days after such conviction;
e) Notifying the agency in writing within ten 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 every grant officer or
other designee on whose grant the convicted employee was working, unless the Federal
agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant
f) Taking one of the following actions within 30 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 drug-free workplace through
implementation of paragraphs (a) through (f),
CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-Children Act of 1994(Act), requires that smoking not be permitted
in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or
regularly for the provision of health, day care, early childhood development services, education or library
services to children under the age of 18, if the services are funded by Federal program either directly or
through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies
to children's services that are provided in indoor facilities that are constructed, operated, or maintained with
such Federal funds. The law does not apply to children's services provided in private residences;portions of
facilities used for inpatient drug or alcohol treatment service providers whose sole source of applicable
Federal funds in medicare of medicaid;or facilities where WIC coupons are redeemed. Failure to comply with
the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each
violation and/or the imposition of an administrative compliance order on the responsible entity.
By signing this certification, the offeror/contractor(for acquisitions) or applicant/grantee (for grants) certifies
that the submitting organization will comply with the requirements of the Act and will not allow smoking within
any portion of any indoor facility used for the provision of services for children as defined by the Act.
The submitting organization agrees that it will require that the language of this certification be included in any
subawards which subrecipients shall certify accordingly.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
By signing and submitting this proposal, the applicant, defined as the primary participant in accordance with 45
CFR Part 76 certifies to the best of his or her knowledge and believe that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from covered transaction by any Federal Department or agency;
(b) have not within a 3-year period preceding this proposal been convicted or had a civil judgement
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 statement, or receiving
stolen property;
(c) are not presently indicted 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 3-year period preceding this application/proposal had one or more public transaction
(Federal, State or local) terminated for cause or default.
The inability of a person to provide the certification required above will not necessarily result in denial of
participation in this covered transaction. If necessary, the prospective participant shall submit an explanation
of why it cannot provide the certification. The Department of Health and Human Services' (HHS)
determination whether to enter into this transaction. However, failure of the prospective primary participant to
furnish a certification or an explanation shall disqualify such person from participation in this transaction.
The prospective primary participant agrees that by submitting this proposal, it will include the clause entitled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered
Transactions,"provided below without modification in all lower tier covered transactions.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS
(TO BE SUPPLIED TO LOWER TIER PARTICIPANTS)
By signing and submitting this lower tier proposal, the prospective lower tier participant, as defined in 45 CFR,
Part 76, certifies to the best of its knowledge and belief that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency.
(b) - where the prospective lower tier participant is unable to certify to any of the above, such prospective
participant shall attach an explanation to this proposal.
The prospective lower tier participant further agrees by submitting this proposal that it will include this clause
entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier
Covered Transactions,"without modification in all lower tier covered transactions and in all solicitations for
lower tier covered transactions.
CERTIFICATION REGARDING LOBBYING
FOR CONTRACTS, GRANTS, LOANS
AND COOPERATIVE AGREEMENTS
The undersigned certifies to the best of his or her knowledge and belief, that:
(1) No Federal appropriate 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 awarding of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) if any funds other than Federal appropriated funds have been paid or will be paid to any person
influencing or attempting to influence an officer or employee or an agency, a member of congress, an
officer or employee of congress, or an employee of a member of congress in connection with this
Federal contract, grant, loan or cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure Form to Report Lobbying,"in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification
shall be subject to a civil penalty or not less than$10,000 and not more than$100,000 for each such failure.
i hereb ree.to the above rtifications and assurances.
• AUG 2 3 2004
Signature of Certifying Official Date
Robert D. Masden, Chair
Title
Weld County. Colorado
Applicant Organization
•
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