Item C15
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
MEETING DATE: APRIL 19, 2000
DIVISION: COMMUNITY SERVICES
BULK ITEM: YES
DEPARTMENT: COMMUNITY SERVICES
AGENDA ITEM WORDING: Approval of the Certification Regarding Lobbying and Certification regarding Debarment,
Suspension and other responsibility matters primary covered transactions, concerning the operation of the Summer
Youth Employment and Training Program.
ITEM BACKGROUND: The grant requires annual approval of these documents,
PREVIOUS RELEVANT BOCC ACTION: Approved by the BOCC on a yearly basis since 1989,
STAFF RECOMMENDATION: Approval.
TOTAL COST: N/A
BUDGETED: N/A
COST TO COUNTY: N/A
REVENUE PRODUCING: N/A
AMOUNT PER MONTH /YEAR:
APPROVED BY: County Attorney
DIVISION DIRECTOR APPROVAL
Risk Management XXX
DOCUMENTATION: Included xxx.
To Follow
Not Required
AGENDA ITEM#~
DISPOSITION:
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
Contract with: Effective Date:
Expiration Date:
Contract Purpose/Description:Certification regarding Lobbying and Certification regarding
Debarment. suspension and other responsibility matters primary covered transtions. concerning
the operation of the Summer Youth Employment and Training Program
Contract Manager:Jim Malloch
(Name)
4500
(Ext,)
Comm, Serv./l
(Department) 1 Courier Stop
for BOCC meeting on 4/19/00
Agenda Deadline: 4/5100
CONTRACT COSTS
Total Dollar Value of Contract: $N/A
Budgeted? YesD No D Account Codes:
Grant: $N/A
County Match: $NI A
Current Year Portion: $NI A
N/A-_-_-_
N/A-_-_-_
N/A-_-_-_
- - -
----
Estimated Ongoing Costs: $NI Nyr
(Not included in dollar value above)
ADDITIONAL COSTS
For: N/A
(e~, maintenance, utilities, ianitorial, salaries, etc.)
CONTRACT REVIEW
Date In
Division Director y J tj JOb
~nag~ment Lf {c,. ()-'
OdBlP~ing 't/d 6 '-'
County Attorney '1/ I.f I t--l-
Comments:
~"Z- ~ C/]~
YeslJ1NoD (\AQ
'\ '/ f ~~,
YesD Noff \ .1 ,a:JI J".:-'
,/.{ ~'/ -:--
YesD NoIT '---ll. (' \,- :..-- LL ( L -,
YeSDNO~
Date Out
LJ/4!DO
4,( /I'
,;f~
!
4'- J{ .! 00
OMB Form Revised 12/13/99
03/30/00 10:37 FAX
III 002
.'
\
CElQJFICATION~AlIDIN!LLOIm'YlNG
CERTIFICAnON FOR CONTRAcrs, GRANTS, LOANS, AND COOPERATIVE
AGREEMENTS
The uncIersigDed c:crtifics, to the best of his 01' hcc knowledge and belief, tbat:
(1) No Federal appropriated fimds have been paid or wiD be paid, by or on behalf of the
undersigned. to any person for iDfluenci:Dg 01' attempting to iDtlueDce an officer or employee of an
agency. a Member of Congress, an officer or employtC of CoDpess. or an employee of a Member
of Congress in coonection with tbaawardins of any FederaI CODIrICt, 1hc IIdlri. of any Federal
grant. the ma~ of any Federal loan. the eDteriDg imo of_any cooperative agreement. and the
c:xIeDSion, C()JJrinwItion. rcocwal. ~, or modificatioo of any Federal (;()~~ grant, loan,
or cooperative agn:emcnt.
(2) If any funds other tban Fcdcral appcopriated funds bave been paid or will be paid to any
person for iDflucnciug Or attempting to iDfluca:c an officer or employ= of any ageDC)'. a Member
of Congress. an officer or employte of CoIIgIess. or an employee of a Member of Congress in
~on wirh this FedcraI contraCt, gram, loan, or cooperative a~, the wxlersigncd 5balI
complete aDd submit Standard Form-ILL. "Disclosure Form to Report Lobbying." in accordance
with its instructions.
(3) The undersigDcd sbaD require that the lquage of this certification be included in the award
(IoI:!I~!Il for an" subawards at an tiers (iDcJudiDg subamtracts. subgrants and comracts under
grams, loaDs, and coopelative ~I"S) and that aU. subrccipients sbaIl c::ertify and disclose
accordiDaly.
This certification is a material repPtenbt10n of fact upon which re1iaDce was placed when this
traDsaction was made or earered into. Submiqion of this c=tification is a prerequisite for 1rn11c11lg or
CIIICriDg into this traDSaCtioD imposed by Section 1352. Title 31, U.S. Code. Any person who fails
to file the required c:ertification sball be subject to a civil penalty of DOt less than $IO.(xx) and DOt
more than $100.000 for each mch failure.
Monroe County Board of County Comadssioners
GranIeeIComractor OrJlInivtjon
S1DIDIler Youth/VIA Youtb
Program/Ttde
Shirley Freeman, Mayor
Name of CenifyIDi 0fticiaI
Sigrwure
Date
.Note: In these ilW~DCfS, "All," in the Final Rule is ~~ to be clarified to show that it applies
to covered coutraaIgram ttaDSaCtioDs over $100.000 (per OMB).
03/30/00 10:38 FAX
III 003
,
CERTIFICATION REGARDlNGJ)EBABMENf. SUS~ON. AIm '
OTHER
RESPONSlRTT.ITV MA'ITERS PRIMARY COVERED TRANSACTIONS
1. The service provider certifies to the best of its kmwledge aDd belief, that it and its
principals:
a. Are DOt prcscntly debam:d. suspcoded. ~ for debarmcat, decJared iDcligiblc.
or whmtarily cXcluaed from covem1 ~ODS by any Federal depanmeDt or
agency.
b. Have DOt within a tbree-year period prw-'n,g this ~ been c:onvicraI of or had
a civil judpmem I'CDdcred agaiDst 1hcm for l'nmmi~sion of fraud or a aimiDa1
offcmc in conNUion with obtaiDiDg, ~ to obIain, or perfotmin,g a public
(FcderaI. State. or local) uansaaiOD or CO.A...1 UDder a public tpn~ violation
of Federal 01' State antitrust stabJta or falsifWoJltinn or dcsIruction of records, 1ml1ri118
false stltements, or receiving stolen propclty;
c. Arc not prcscndy iQdicted for or otherwise c:rimina11y or civilly charged by a
govemmcol entity (Fedela1. State. or local) with Nmnniccion of any of tbe offenses
~~1tM in paragraph l.b of this cenificuion; and
d. Have DOt within a thrce-ycar period ~iDg this application/proposal had one or
more public transactions (Federal. State, or local) termituatNl for cause or default.
2. Where the prospective primary participam is mablc to certify to any ofthc JUteda;DtS in this
CCltificatiou. such prospective particjp;mt sba11 submit an explanation to SFETC.
Monroe County Board of County COIIIIIlissioners
SERVICE PROVIDER AGENCY
Shirley Freeman, Mayor
NAME OF CERTIf'YD"fG OffiCIAL
SIGNATURE OF Cl::KIU-tING OffiCIAL
DATE
BJUO.47.FRM
OS.OS.3IltS