ESBD_383500_1732791815964_Appendix F - Assurances.docx
DOCX document 81 KB Posted
- Attached to
- STDC Far West Texas RFP No 25-01. 02. 03.
- Solicitation number
- STDC_FARWEST-TEXAS_RFP-NO_25-01.02.03.
- Issued by
- Comal County, Texas
About this file
This is an assurances and certifications document from the South Texas Development Council (STDC) and Texas Department of State Health Services (DSHS) for HIV/AIDS service providers. The document contains multiple required forms (Forms H through P) that contractors must complete to provide HIV-related services, including assurances regarding HIV confidentiality, pharmacy notification, sanctions compliance, standing delegation orders, training requirements, and materials review processes.
The document outlines extensive compliance requirements regarding drug-free workplace policies, non-discrimination practices, environmental standards, financial management, and various federal and state regulations. Key requirements include maintaining proper accounting systems, safeguarding client confidentiality, preventing conflicts of interest, and adhering to federal grant management standards. Contractors must certify they are not debarred from federal contracts, comply with lobbying restrictions, and maintain various professional standards around HIV service delivery. The document includes multiple signature blocks requiring certification from authorized officials of contracting organizations.
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FORM H: HIV ASSURANCES
1. ADVOCATE AND PROMOTE
The applicant agency assures that it does not advocate or promote conduct that violates state law, in compliance with the HIV Services Act, Texas Health and Safety Code, Section 85.011, as follows:
"Grants may not be awarded to an entity or community organization that advocates or promotes conduct that violates state law. This subsection does not prohibit the award of a grant to an entity or community organization that provides accurate information about ways to reduce the risk of exposure to or transmission of HIV."
2. CONFIDENTIALITY
The applicant agency and its employees or subcontractors, if applicable, provide assurance to the South Texas Development Council (STDC) and the Texas Department of State Health Services (DSHS) that confidentiality of all records shall be maintained. No information obtained in connection with the examination, care, or provision of programs or services to any person with HIV shall be disclosed without the individual's consent, except as may be required by law, such as for the reporting of communicable diseases. Information may be disclosed in statistical or other summary form, but only if the identity of the individuals diagnosed or provided care is not disclosed.
We are aware that the Health and Safety Code, §81.103, provides for both civil and criminal penalties against anyone who violates the confidentiality of persons protected under the law. Furthermore, all employees and volunteers who provide direct client care services or handle direct care records wherein they may be informed of a client's HIV status or any other information related to the client's care, are required to sign a statement of confidentiality assuring compliance with the law. An entity that does not adopt a confidentiality policy as required by law is not eligible to receive state funds until the policy is developed and implemented.
3. CONFLICT OF INTEREST
The applicant agency and its employees or subcontractors, if applicable, provide assurance to the STDC and DSHS that no person who is an employee, agent, consultant, officer, board member, or elected or appointed official of this agency, and, therefore, in a position to obtain a financial interest or benefit from an activity, or an interest in any contract, subcontract, or agreement with respect thereto, or the proceeds there under, either for himself or herself or for those with whom he or she has family or business ties, during his or her tenure or for one year thereafter shall participate in the decision making process or use inside information with regard to such activity. Furthermore, this agency will adopt procedural rules which require the affected person to withdraw from his or her functions and responsibilities or the decision-making process with respect to the specific assisted activity from which they would derive benefit.
4. TUBERCULOSIS COLLABORATION
The applicant agency assures the STDC and DSHS that it maintains collaborative efforts with local Tuberculosis (TB) Control programs in order to assure that HIV and TB treatment and prevention services are provided to persons at risk of HIV and TB.
5. DRUG-FREE WORKPLACE REQUIREMENTS
The undersigned (authorized official signing for the applicant organization) certifies that it will provide a drug-free workplace in accordance with 45 CFR Part 76 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, and 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 the statement required by paragraph (a) above; | |
| (d) | Notifying the employee in the statement required by paragraph (a), above, 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 within ten days after receiving notice under subparagraph (d)(2), above, from an employee or otherwise receiving actual notice of such conviction; |
| (f) | Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), above, with respect to any employee who is so convicted: |
(1) Taking appropriate personnel action against such an employee, up to and including termination; 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), (b), (c), (d), (e), and (f), above. |
6. POLICIES OF THE HIV/STD Prevention and Care Branch
The applicant agency assures the STDC and DSHS that it will abide by all policies of the HIV/STD Comprehensive Services Branch that apply to the programs being provided. A list of policies applicable to all HIV and STD contractors is provided at the Branch website at https://www.dshs.texas.gov/hivstd/policy/.
Signature of Authorized Certifying Official
Title
Date
Legal Name of Applicant Organization
FORM I: NONPROFIT BOARD OF DIRECTORS AND EXECUTIVE DIRECTOR ASSURANCES FORM
If the applicant is a nonprofit organization, this form must be completed (state or other governmental agencies are not required to complete this form). The purpose of the form is to inform nonprofit board members and officers of the responsibilities and administrative oversight requirements of nonprofit applicants intending to or contracting with South Texas Development Council (STDC).
(Name & Address of Organization)
The persons signing on behalf of the above-named organization certify that they are duly authorized to sign this Assurances form on behalf of the organization. The undersigned acknowledge and affirm:
A. That an annual budget has been approved for each contract with STDC and DSHS.
B. The Board of Directors convenes on a regularly scheduled basis (no less than quarterly) to discuss the operations of the organization.
C. Actual revenue and expenses are compared with the approved budget, variances are noted, and corrective action taken as needed (with Board approval).
D. Timely and accurate financial statements are presented by the designated financial officer on a regular basis to the board.
E. That the Board of Directors will ensure that any required financial reports and forms, whether federal or state, are filed on a current and timely basis.
F. Adequate internal controls are in place to ensure fiscal integrity and accountability and to safeguard assets.
G. The Treasurer of the Board has been fully informed of his or her responsibilities as Treasurer.
H. The Board has Audit and/or Finance Committees that convene regularly and communicate effectively with the Board Treasurer and other Board members in understanding and responding to financial developments.
| I. | The organization observes Generally Accepted Accounting Principles when preparing financial statements and fund accounting practices are observed to ensure integrity among specific contracts or grants. |
| J. | If a contract is executed with STDC, this form will be discussed in detail at the next official Board meeting and that notes of the discussion and a signed copy of this form will be included in the minutes of the meeting. A copy of the minutes will be kept at the organization and be available for inspection by STDC and DSHS staff. |
K. If a contract is executed with the STDC and the nonprofit organization has not received any funding from STDC and DSHS for the past 24 months, the Legal and Fiscal Responsibilities for Nonprofit Board of Directors Video and Guide will be viewed and a signed “tear-out” sheet will be completed and filed by each board member with the nonprofit organization no later than 45 days after contract execution. Newly appointed/elected board members will comply with these requirements no more than 45 days after taking office. All tear-out sheets will be available for inspection by STDC and DSHS staff.
L. The organization will administer any contract executed with the STDC in accordance with applicable federal statutes and regulations, including federal grant requirements applicable to funding sources, Uniform Grant Management Standards issued by the Governor’s Office, applicable Office of Management and Budget Circulars, applicable Code of Federal Regulations, and provisions of the contract document.
*Chairman of the Board Signature/Date
*President or Executive Director Signature/Date
*If the signed original of this form has been provided to STDC during the calendar year and the officers signing the document have not changed, a copy of the signed form will be accepted.
FORM J: CONTRACTOR ASSURANCE REGARDING PHARMACY NOTIFICATION
South Texas Development Council HIV Administrative Agency Program
Contractor Assurance Regarding Pharmacy Notification
To ensure that pharmacies providing prescriptions to HIV services clients do not fill medications on deceased clients, the applicant agency provides assurance to the South Texas Development Council and the Department of State Health Services that it will notify the client's pharmacy when a client expires.
Signature of Authorized Certifying Official
Title
Date
Legal Name of Applicant Organization
FORM K: CONTRACTOR ASSURANCE FORM SANCTIONS FOR
CLIENT ABUSE AND/OR NEGLECT
Assurance from Sanctions for Client Abuse and/or Neglect
| Service Provider Name: |
| Address: |
| Phone: |
| Funding Source: |
| Contact Person: |
Service Provider certifies that the agency has been free of sanctions from other funding sources (e.g., Ryan White Part A, C or D) for evidence of client abuse and/or neglect since being awarded the contract.
Service Provider understands that the agency will be monitored by the administrative agency for compliance with this statement of assurance during programmatic monitoring of the agency. Service Provider also understands that a false statement of being sanction free may result in sanctions or termination of contract for funding.
Signature of Authorized Certifying Official
Title
Date
FORM L: CONTRACTOR ASSURANCE FORM SANCTIONS FOR
EVIDENCE OF CHILD ABUSE AND/OR NEGLECT
Assurance of Compliance from Sanctions for Evidence of Child Abuse and/or Neglect DSHS Policy 530.001
| Service Provider Name: |
| Address: |
| Phone: |
| Funding Source: |
| Contact Person: |
Service Provider certifies that the agency has been free of sanctions from funding source for evidence of child abuse and/or neglect since being awarded the contract.
Service Provider is aware that the agency must comply with DSHS HIV/STD Policy No. 530.001. Agency has review this policy and all of its corresponding forms located at (https://www.dshs.texas.gov/dshs-ems-trauma-systems/links-resources-references/child-abuse-reporting-requirements) and can comply with the entire requirements of this policy.
Service Provider understands that the agency will be monitored by the administrative agency for compliance with this policy during clinical monitoring of the agency. Service Provider also understands that non-compliance with this policy may result in sanctions or termination of contract for funding.
Signature of Authorized Certifying Official
Title
Date
FORM M: CONTRACTOR ASSURANCE OF COMPLIANCE WITH
STANDING DELEGATION ORDERS
Assurance of Compliance with Standing Delegation Orders
| Service Provider Name: |
| Address: |
| Phone: |
| Funding Source: |
| Contact Person: |
Service Provider certifies that the agency is in compliance with the requirement for having current updated Standing Delegation Orders.
Service Provider understands that the agency will be monitored by the administrative agency for compliance with these requirements during the clinical/case management monitoring of the agency. Service Provider also understands that non-compliance with this policy may result in sanctions or termination of contract for funding.
Signature of Authorized Certifying Official
Title
Date
FORM N: CONTRACTOR ASSURANCE OF COMPLIANCE
WITH TRAINING, EDUCATION, AND LICENSURE
Assurance of Compliance with Training, Education, and Licensure
| Service Provider Name: |
| Address: |
| Phone: |
| Funding Source: |
| Contact Person: |
Service Provider certifies that all agency staff that is funded under the RWSD/State/SS grants are in compliance with all of the training, education, and licensure requirements.
Service Provider understands that the agency will be monitored by the administrative agency for compliance with these requirements during the programmatic monitoring of the agency. Service Provider also understands that non-compliance with this policy may result in sanctions or termination of contract for funding.
Signature of Authorized Certifying Official
Title
Date
FORM O: CONTRACTOR ASSURANCE OF COMPLIANCE WITH THE
REQUIREMENTS FOR CONTENTS OF AIDS RELATED
WRITTEN MATERIALS
Assurance of Compliance with the “Requirements for Contents of AIDS-Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions in HIV Services Programs Funded by STDC/DSHS”
| Service Provider Name: |
| Address: |
| Phone: |
| Funding Source: |
| Contact Person: |
By signing and submitting this form, the applicant certifies that the agency is in compliance with the “Requirements for Contents of AIDS-Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions” to review and approve all applicable materials prior to their distribution and use in any activities funded in any part with Ryan White Part B, Ryan White Supplemental, State, State-R and State Services. The applicant assures that it will follow the process set forth by the “Centers for Disease Control and Prevention (CDC)” as revised June 15, 1992, 57 Federal Register 26742 which is required by the South Texas Development Council and Department of State Health Services for the Material Review Panel Requirement which is available at https://www.cdc.gov/hiv/pdf/funding/announcements/ps21-2102/cdc-hiv-content-review-program-guidance-2016.pdf.
The applicant understands that the agency will be monitored by the administrative agency for compliance with this requirement during the programmatic monitoring of the agency. The applicant also understands that non-compliance with this policy may result in sanctions or termination of contract for funding.
Signature of Authorized Certifying Official
Title
Date
FORM P: DSHS ASSURANCES AND CERTIFICATIONS
Note: Some of these Assurances and Certifications may not be applicable to your project. If you have questions, contact the contact person named in this application. These assurances and certifications shall remain in effect throughout the project period of this solicitation and the term of any contract between respondent and STDC/DSHS.
As the duly authorized representative of the respondent, my signature certifies that the respondent:
1. Is a legal entity legally authorized and in good standing to do business with the State of Texas and has the legal authority to apply for state/federal assistance, and has the institutional, managerial and financial capability and systems (including funds sufficient to pay the non-state/federal share of project costs) to ensure proper planning, management and completion of the project described in this proposal; possesses legal authority to apply for funding; that a resolution, motion or similar action has been duly adopted or passed as an official act of the respondent’s governing body, authorizing the filing of the proposal including all understandings and assurances contained therein, and directing and authorizing the person identified as the authorized representative of the respondent to act in connection with the proposal and to provide such additional information as may be required;
2. Certifies that under Government Code Section 2155.004, the individual or entity (respondent) is not ineligible to receive the specified contract and acknowledges that this contract may be terminated and payment withheld if this certification is incorrect. NOTE: Under Government Code Section 2155.004, a respondent is ineligible to receive an award under this RFP if the bid includes financial participation with the respondent by a person who received compensation from DSHS to participate in preparing the specification of RFP on which the bid is based.
3. Has a financial system that: identifies the source and application of DSHS funds in a unique set of general ledger account numbers, permits preparation of reports required by the tract, permits the tracing of funds expended and program income, allows for the comparison of actual expenditures to budgeted amounts; and maintains accounting records that are supported by verifiable source documents.
4. A parent, affiliate, or subsidiary organization, if such a relationship exists, will give DSHS, HHSC Office of Inspector General, the Texas State Auditor, the Comptroller General of the United States, and if appropriate, the federal government, 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;
| 5. | Will supplement the project/activity with funds other than the funds made available through a contract award as a result of this RFP and will not supplant funds from that contract to replace or substitute existing funding from other sources; |
| 6. | 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; |
7. Will comply, as a sub grantee, with Texas Government Code, Chapter 573, Vernon’s 1994, by ensuring that no officer, employee, or member of the respondent’s governing body or of the respondent’s contractor shall vote or confirm the employment of any person related within the second degree of affinity or the third degree of consanguinity to any member of the governing body or to any other officer or employee authorized to employ or supervise such person. This prohibition shall not prohibit the employment of a person who shall have been continuously employed for a period of two years, or such other period stipulated by local law, prior to the election or appointment of the officer, employee, or governing body member related to such person in the prohibited degree;
8. Has not given, nor intends to give, at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or any employee or representative of same, in connection with this procurement; Does not have nor shall it knowingly acquire any interest that would conflict in any manner with the performance of its obligations under any awarded contract that results from this RFP;
9. Will honor for 90 days after the proposal due date the technical and business terms contained in the proposal;
10. Will initiate the work after receipt of a fully executed contract and will complete it within the contract period;
11. Will not require a client to provide or pay for the services of a translator or interpreter;
12. Will identify and document on client records the primary language/dialect of a client who has limited English proficiency and the need for translation or interpretation services;
13. Will make every effort to avoid use of any persons under the age of 18 or any family member or friend of a client as an interpreter for essential communications with clients who have limited English proficiency. However, a family member or friend may be used as an interpreter if this is requested by the client and the use of such a person would not compromise the effectiveness of services or violates the client’s confidentiality, and the client is advised that a free interpreter is available;
14. Will comply with the requirements of the Immigration Reform and Control Act of 1986, 8 USC §1324a, as amended, regarding employment verification and retention of verification forms for any individual(s) hired on or after November 6, 1986, who will perform any labor or services proposed in this proposal;
| 15. | Agrees to comply with the following to the extent such provisions are applicable: |
| A. | Title VI of the Civil Rights Act of 1964, 42 USC§§2000d, et seq.; |
| B. | Section 504 of the Rehabilitation Act of 1973, 29 USC §794(a); |
C. The Americans with Disabilities Act of 1990, 42 USC §§12101, et seq.;
| D. | All amendments to each and all requirements imposed by the regulations issued pursuant to these acts, especially 45 CFR Part 80 (relating to race, color and national origin), 45 CFR Part 84 (relating to handicap), 45 CFR Part 86 (relating to sex), and 45 CFR Part 91 (relating to age); |
| E. | DSHS Policy AA-5018, Non-Discrimination Policies and Procedures for DSHS Programs, which prohibits discrimination on the basis of race, color, national origin, religion, sex, sexual orientation, age, or disability; and |
| F. | Any other nondiscrimination provision in specific statures under which application for federal or state assistance is being made. |
16. Will comply with the Uniform Grant Management Act (UGMA), Texas Government Code, Chapter 783, and the Texas Grants Management Standards (TxGMS), which apply as terms and conditions of any resulting contract. A copy of the TxGMS manual is available upon request. TxGMS is better aligned with the federal Uniform Guidance in 2 CFR, Part 200. It is developed under the authority of Gov't Code Ch. 783 to promote the efficient use of public funds in local government and in programs requiring cooperation among local, state, and Federal agencies;
17. Will remain current in its payment of franchise tax or is exempt from payment of franchise taxes, if applicable;
18. Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child Support, and certifies that it is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract may be terminated and payment may be withheld if this certification is inaccurate;
19. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin, or age;
| 20. | Will comply with environmental standards prescribed pursuant to the following: |
| A. | Institution of environmental quality control measures under the National Environmental Policy Act of 1969, 42 USC §§4321-4347, and Executive Order (EO) 11514 (35 Fed. Reg. 4247), "Protection and Enhancement of Environmental Quality"; |
| B. | Notification of violating facilities pursuant to EO 11738 (40 CFR, Part 32), "Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect to Federal Contracts, Grants or Loans"; |
| C. | Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, as amended, 42 USC §§7401 et seq.; and |
| D. | Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§300f-300j, as amended; |
| 21. | Will comply with the Pro-Children Act of 1994, 20 USC §§6081-6084, regarding the provision of a smoke-free workplace and promoting the non-use of all tobacco products; |
22. Will comply, if applicable, with National Research Service Award Act of 1971, 42 USC §§289a-1 et seq., as amended and 6601 (P.L. 93-348 – P.L. 103-43), as amended, regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance, as implemented by 45 CFR Part 46, Protection of Human Subjects;
23. Will comply, if applicable, with the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 USC §263a, as amended, which establish federal requirements for the regulation and certification of clinical laboratories;
24. Will comply, if applicable, with the Occupational Safety and Health Administration Regulations on Blood-borne Pathogens, 29 CFR §1919.030, which set safety standards for those workers and facilities in the private sector who may handle blood-borne pathogens, or Title 25 Texas Administrative Code, Chapter 96, which affects facilities in the public sector;
25. Will not charge a fee for profit. A profit or fee is considered to be an amount in excess of actual allowable costs that are incurred in conducting an assistance project;
26. Will comply with all applicable requirements of all other state/federal laws, executive orders, regulations, and policies governing this program;
| 27. | As the primary participant in accordance with 45 CFR Part 76, respondent 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 a 3-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 or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) of this certification; |
| D. | Have not within a 3-year period preceding this proposal/proposal had one or more public transactions (federal, state, or local) terminated for cause or default; and |
| E. | Has not (nor has its representative nor any person acting for the representative) (1) violated the antitrust laws codified by Chapter 15, Business & Commercial Code , or the federal antitrust laws; or (2) directly or indirectly communicated the bid to a competitor or other person engaged in the same line of business. |
Should the respondent not be able to provide this certification (by signing the FACE PAGE Form), an explanation should be placed after this form in the proposal response;
The respondent agrees by submitting this proposal that he/she will include, without modification, the clause titled “Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transaction” (Appendix B to 45 CFR Part 76) in all lower tier covered transactions (i.e., transactions with sub grantees and/or contractors) and in all solicitations for lower tier covered transactions;
28. Will comply with Title 31, USC §1352, entitled “Limitation on use of appropriated funds to influence certain federal contracting and financial transactions,” which generally prohibits recipients of federal grants and cooperative agreements from using federal (appropriated) funds for lobbying the executive or legislative branches of the federal government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a federal grant or cooperative agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93):
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 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;
B. If any funds other than federally-appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agent, 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 of Lobbying Activities,” (SF-LLL) in accordance with its instructions. SF-LLL and continuation sheet are available upon request from the Department of State Health Services; and C. The language of this certification shall be included in the award documents for all sub-awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans and cooperative agreements) and that all sub recipients 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 31 USC §1352. 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;
| 29. | Is in good standing with the Internal Revenue Service on any debt owed; |
| 30. | Certifies that no person who has an ownership or controlling interest in the organization or who is an agent or managing employee of the organization has been placed on community supervision, received deferred adjudication or been convicted of a criminal offense related to any financial matter, federal or state program or felony sex crime; |
31. Is in good standing with all state and/or federal departments or agencies that have a contracting relationship with the respondent;
| 32. | Statutes and Standards of General Applicability. It is Contractor’s responsibility to review and comply with all applicable statutes, rules, regulations, executive orders and policies. Contractor shall carry out the terms of this Contract in a manner that is in compliance with the provisions set forth below. To the extent such provisions are applicable to Contractor; Contractor agrees to comply with the following: | |
| a) | The following statutes that collectively prohibit discrimination on the basis of race, color, national origin, limited English proficiency, sex, sexual orientation, disabilities, age, substance abuse or religion: 1) Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. §§ 2000d et seq.; 2) Title IX of the Education Amendments of 1972, 20 U.S.C.A. §§ 1681-1683, and 1685-1686; 3) Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. § 794(a); 4) the Americans with Disabilities Act of 1990, 42 U.S.C.A. §§ 12101 et seq.; 5) Age Discrimination Act of 1975, 42 U.S.C.A. §§ 6101-6107: 6) Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, 42 U.S.C.A. § 290dd (b)(1); 7) 45 CFR Parts 80, 84, 86 and 91; and 8) TEX. LAB. CODE. ch. 21; DSHS Policy AA-5018, Non-discrimination Policies and Procedures for DSHS Programs; | |
| b) | Drug Abuse Office and Treatment Act of 1972, 21 U.S.C.A. §§ 1101 et seq., relating to drug abuse; | |
| c) | Public Health Service Act of 1912, §§ 523 and 527, 42 U.S.C.A. § 290dd-2, and 42 C.F.R. pt. 2, relating to confidentiality of alcohol and drug abuse patient records; | |
| d) | Title VIII of the Civil Rights Act of 1968, 42 U.S.C.A. §§ 3601 et seq., relating to nondiscrimination in housing; | |
| e) | Immigration Reform and Control Act of 1986, 8 U.S.C.A. § 1324a, regarding employment verification; | |
| f) | Pro-Children Act of 1994, 20 U.S.C.A. §§ 6081-6084, regarding the non-use of all tobacco products; | |
| g) | National Research Service Award Act of 1971, 42 U.S.C.A. §§ 289a-1 et seq., and 6601 (P.L. 93-348 and P.L. 103-43), as amended, regarding human subjects involved in research; | |
| h) | Hatch Political Activity Act, 5 U.S.C.A. §§ 7321-26, which limits the political activity of employees whose employment is funded with federal funds; | |
| i) | Fair Labor Standards Act, 29 U.S.C.A. §§ 201 et seq., and the Intergovernmental Personnel Act of 1970, 42 U.S.C.A. §§ 4701 et seq., as applicable, concerning minimum wage and maximum hours; | |
| J) | TEX. GOV’T CODE ch. 469 (Supp. 2004), pertaining to eliminating architectural barriers for persons with disabilities; | |
| k) | Texas Workers’ Compensation Act, TEX. LABOR CODE, chs. 401-406 28 TEX. ADMIN. CODE pt. 2, regarding compensation for employees’ injuries; | |
| l) | The Clinical Laboratory Improvement Amendments of 1988, 42 USC § 263a, regarding the regulation and certification of clinical laboratories; | |
| m) | The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR § 1910.1030, or Title 25 Tex. Admin Code ch. 96 regarding safety standards for handling blood borne pathogens; | |
| n) | Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq., pertaining to the treatment of laboratory animals; | |
| o) | Environmental standards pursuant to the following: 1) Institution of environmental quality control measures under the National Environmental Policy Act of 1969, 42 USC §§ 4321-4347 and Executive Order 11514 (35 Fed. Reg. 4247), “Protection and Enhancement of Environmental Quality;” 2) Notification of violating facilities pursuant to Executive Order 11738 (40 CFR Part 32), “Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with respect to Federal Contracts, Grants, or Loans;” 3) Protection of wetlands pursuant to Executive Order 11990, 42 Fed. Reg. 26961; 4) Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42 Fed. Reg. 26951 and, if applicable, flood insurance purchase requirements of Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234); 5) Assurance of project consistency with the approved State Management program developed under the Coastal Zone Management Act of 1972, 16 USC §§ 1451 et seq; 6) Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, as amended, 42 USC §§ 7401 et seq.; 7) Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§ 300f-300j; 8) Protection of endangered species under the Endangered Species Act of 1973, 16 USC §§ 1531 et seq.; 9) Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, 42 USC §7401 et seq.; 10) Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§300f-330j; 11) Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to protecting certain rivers system; and 12) Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801 et seq.) prohibiting the use of lead-based paint in residential construction or rehabilitation; | |
| p) | Intergovernmental Personnel Act of 1970 (42 USC §§4278-4763 regarding personnel merit systems for programs specified in Appendix A of the federal Office of Program Management’s Standards for a Merit System of Personnel Administration (5 C.F.R. Part 900, Subpart F); | |
| q) | Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646), relating to fair treatment of persons displaced or whose property is acquired as a result of Federal or federally-assisted programs; |
| r) | 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 sub agreements; | |
| s) | Assist DSHS in complying the National Historic Preservation Act of 1966, §106 (16 U.S.C. § 470), Executive Order 11593, and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§ 469a-1 et seq.) regarding historic property; | |
| t) | Financial and compliance audits in accordance with Single Audit Act Amendments of 1996 and OMB Circular No. A-133, “Audits of States, Local Governments, and Non-Profit Organizations”; and | |
| u) | Requirements of any other applicable statutes, executive orders, regulations and policies. |
If this Contract is funded by a grant, additional requirements found in the Notice of Grant Award may be imposed on Contractor.
33. Affirms that the statements herein are true, accurate, and complete (to the best of his or her knowledge and belief) and agrees to comply with all terms and conditions if an award is issued as a result of this proposal. Willful provision of false information is a criminal offense (Title 18, USC §1001). Any person making any false, fictitious, or fraudulent statement may, in addition to other remedies available to the Government, be subject to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR Part 79).
Signature of Authorized Certifying Official
Title
Date
Legal Name of Applicant Organization
FY10 HOPWA RENEWAL APPLICATION
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