2-Certifications.pdf

CERTIFICATION REGARDING

DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS

PRIMARY COVERED TRANSACTIONS

Applicant/Contractor Legal Name:

This certification is required by the regulations implementing Executive Order 12549 Debarment and Suspension 29 CFR Part 98. Section 98.510. Participant’s Responsibilities. The regulations were published as Part VII of the May 26, 1988 Federal Register (Pages 191601-19211).

(Before signing certification read instructions which are an integral part of the certification)

(1) The prospective primary participant, (i.e, grantee) 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, covered transactions by any Federal department or agency;

(b) Have not, within the three-year period preceding this proposal, 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 government 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 preceded this application/proposal, had one or more public transactions (Federal, State, Local) terminated for cause or default.

(2) When the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.

NAME AND SIGNATURE OF AUTHORIZED CERTIFYING

OFFICIAL

TITLE

LEGAL NAME OF APPLICANT/CONTRACTOR DATE SUBMITTED

UNIQUE ENTITY ID (if applicable) EIN/TAX ID#

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STATE OF CALIFORNIA

DRUG-FREE WORKPLACE CERTIFICATION

COMPANY/ORGANIZATION NAME:

The contractor or grant recipient named above hereby certifies compliance with Government Code section 8355 in matters relating to providing a drug free workplace. The above named contractor will:

1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation, possession, or use of controlled substance is prohibited and specifying actions to be taken against employees for violations as required by Government Code Section 8355(a).

2. Establish a Drug-Free Awareness program as required by Government Code Section 8355(b), to inform employees about all of the following:

a) The dangers of drug abuse in the workplace,

b) The person’s or organization’s policy of maintaining a drug-free workplace,

c) Any available counseling, rehabilitation and employee assistance programs, and

d) Penalties that may be imposed upon employees for drug abuse violations,

3. Provide as required by Government Code Section 8355(c) that every employee who works on the proposed contract or grant:

(a) Will receive a copy of the company’s drug-free policy statement, and

(b) Will agree to abide by the terms of the company’s statement as a condition of employment on the contract or grant.

CERTIFICATION

I, the official named below, hereby swear that I am duly authorized legally to bind the contractor or grant recipient to the above described certification. I am fully aware that this certification, executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California.

OFFICIAL’S NAME: ____________________________

DATE EXECUTED EXECUTED IN THE COUNTY OF

CONTRACTOR OR GRANT RECIPIENT SIGNATURE

TITLE

FEDERAL TAX ID. NUMBER UNIQUE ENTITY ID (if applicable)

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CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS, LOANS,

AND CORPORATE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) 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 an agency, a Member of Congress, or 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 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 contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, Disclosure Form to Report Lobbying, in according with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for 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 of not less than $10,000 and not more than $100,000 for each such failure.

Grantee/Contractor Organization

Unique Entity ID (if applicable) EIN/TIN #

Name and Title of Authorized Signatory

Signature Date

Note: In these instances, (*) applies to covered contract/grant transactions over $100,000 (per OMB).

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Rev. 12.24

VENDOR ASSURANCE OF COMPLIANCE WITH

THE _________________ COUNTY

WELFARE DEPARTMENT

NONDISCRIMINATION IN STATE

AND FEDERALLY ASSISTED PROGRAMS

NAME OF VENDOR/RECIPIENT _____________________________

HEREBY AGREES THAT it will comply with Title VI and VII of the Civil Rights Act of 1964 as amended;

Section 504 of the Rehabilitation Act of 1973 as amended; the Age Discrimination Act of 1975 as amended;

the Food Stamp Act of 1977, as amended and in particular Section 272.6; Title II of the Americans with Disabilities Act of 1990; California Civil Code Section 51, et seq., as amended; California Government Code Section 11135-11139.8, as amended; California Government Code Section 12940; California Government Code Section 4450; Title 22, California Code of Regulations Section 98000 – 98413; Title 24 of the California Code of Regulations, Section 3105A(e); the Dymally-Alatorre Bilingual Services Act (California Government Code Section 7290-7299.8); Section 1808 of the Removal of Barriers to Interethnic Adoption Act of 1996; and other applicable federal and state laws, as well as their implementing regulations [including 45 Code of Federal Regulations (CFR) Parts 80, 84, and 91, 7 CFR Part 15, and 28 CFR Part 42], by ensuring that employment practices and the administration of public assistance and social services programs are nondiscriminatory, to the effect that no person shall because of ethnic group identification, age, sex, sexual orientation, gender identity, color, disability, medical condition, national origin, race, ancestry, marital status, religion, religious creed, political belief, or other applicable protected basis be excluded from participation in or be denied the benefits of, or be otherwise subject to discrimination under any program or activity receiving federal or state financial assistance; and HEREBY GIVE ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement.

THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all federal and state assistance; and THE VENDOR/RECIPIENT HEREBY GIVES ASSURANCE THAT administrative methods/procedures which have the effect of subjecting individuals to discrimination or defeating the objectives of the California Department of Social Services (CDSS) Manual of Policies and Procedures (MPP) Division 21, will be prohibited.

BY ACCEPTING THIS ASSURANCE, the vendor/recipient agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of the aforementioned laws, rules and regulations and permit authorized CDSS and/or federal government personnel, during normal working hours, to review such records, books and accounts as needed to ascertain compliance. If there are any violations of this assurance, CDSS shall have the right to invoke fiscal sanctions or other legal remedies in accordance with Welfare and Institutions Code Section 10605, or Government Code Section 11135-11139.8, or any other laws, or the issue may be referred to the appropriate federal agency for further compliance action and enforcement of this assurance.

THIS ASSURANCE is binding on the vendor/recipient directly or through contract, license, or other provider services, as long as it receives federal or state assistance.

Vendor/Recipient Authorized Representative’s Signature

Date Address of vendor/recipient

CR-50 Vendor Assurance of Compliance

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VENTURA

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