Federal Forms.pdf

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILIY MATTERS 00310-1

EPA Project Control Number

United State Environmental Protection Agency

Washington, DC 20460 Certification Regarding

Debarment, Suspension, and Other Responsibility Matters EPA Form 5700-49 (11-83)

The prospective participant 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 agencies.

b. Have not within a three year period preceding this proposal been convicted of or had a civil judgment rendered against them for the 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 preceding this application/proposal had one or more public transaction (Federal, State, or local) terminated for cause or default.

I understand that a false statement on this certification may be grounds for rejection of this proposal or termination of the award. In addition, under 18 USC Sec. 1001, a false statement may result in a fine up to $10,000 or imprisonment for up to 5 years, or both.

Type Name & Title of Authorized Representative

Signature of Authorized Representative

Date

I am unable to certify to the above statements. My explanation is attached.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILIY MATTERS 00310-2

Instructions Under Executive Order 12549, an individual or organization debarred or excluded from participation in Federal assistance or benefit programs may not receive any assistance award under a Federal program, of a sub agreement thereunder for $25,000 or more.

Accordingly, each prospective recipient of an EPA grant, loan, or cooperative agreement and any contract or sub agreement participant thereunder must complete the attached certification or provide an explanation why they cannot.

For further details, see 40 CFR 32.510, Participants' responsibilities, in the attached regulation.

Where To Submit The prospective EPA grant. loan, or cooperative agreement recipient must return the signed certification of explanation with its application to the appropriate EPA Headquarters or Regional office, as required in the application instructions.

A prospective prime contractor must submit a completed certification or explanation to the individual or organization awarding the contract.

Each prospective subcontractor must submit a completed certification or explanation to the prime contractor for the project.

How To Obtain Forms:

EPA includes the certification form, instructions, and a copy of its implementing regulation (40) CFR Part 32) in each application kit. Applicants may reproduce these materials as needed and provide them to their prospective prime contractors, who, in turn may reproduce and provide them to prospective subcontractors.

Additional copies/assistance may be requested from:

Compliance Branch Grants Administration Division (PM-216F) US Environmental Protection Agency 401 M St SW Washington DC 20460 (Telephone: 202-475-8025)

MINORITY/WOMEN BUSINESS ENTERPRISE 00320-1

EPA Region VII Procedures for Implementation of 40 CFR Part 33.240 (Minority Business Enterprise/Women’s Business Enterprise)

The following information must be contained in solicitation documents for construction contracts and engineering agreements pursuant to 40 CFR Part 33.240)

Each bidder/offeror must fully comply with the requirements, terms, and conditions of EPA’s policy to award a fair share of sub agreements to minority and women’s businesses. The bidder/offeror commits itself to taking affirmative steps contained herein. Bidders/offerors will take affirmative steps prior to submission of bid/proposal.

Affirmative Steps

A. When feasible, segmenting total work requirements to permit maximum MBE/WBE participation.

B. Assuring that MBEs and WBEs are solicited whenever they are potential sources of goods or services. This step may include:

1. Sending letters or making other personal contacts with MBEs and WBEs, (e. g. those whose name appear on lists prepared by EPA or the grantee and other MBE/WBEs known to the bidder/offeror.) MBEs and WBEs should be contacted when other potential subcontractors are contacted, within reasonable time (fifteen days) prior to bid submission or closing date for receipt of initial offers. Those letters or other contacts should communicate the following:

a. Specific description of the work to be subcontracted;

b. How and where to obtain a copy of the drawings and specifications or other detailed information needed to prepare a detailed price quotation;

c. Date the quotation is due to the bidder/offeror;

d. Name, address, and phone number of the person in the bidder/offeror’s firm whom the prospective

MBE/WBE subcontractor should contact for additional information.

2. Sending letters or making other personal contacts with local, state, federal and private agencies and MBE/WBE associations relevant to the project. Such contacts should provide the same information provided in the direct contacts to MBE and WBE firms.

C. Where feasible, establishing delivery schedules which will encourage participation by MBE and WBEs.

Determination of Compliance It is to be noted that bidders/offerors must demonstrate compliance with MBE/WBE requirements in order to be deemed responsible. Demonstration of compliance shall include, but is not limited to, the following information:

1. Names, addresses and phone numbers of MBE/WBEs expected to perform the work;

2. Work to be performed by MBEs and WBEs;

3. Aggregate dollar amount of work to be performed by MBEs and WBEs, showing aggregate to MBEs and aggregate to WBEs separately;

4. Description of contacts to MBE and WBE organizations, agencies and associations which serve MBE/WBEs, including names of organizations, agencies and associations and dates of contacts;

5. Description of contacts to MBEs and WBEs, including number of contacts, fields, (i. e. equipment or material supplier, excavator, transport services, electrical subcontractors, plumbers, etc.) and dates of contacts.

All bidders/offerors should complete the Minority and Women’s Business Enterprise Utilization Worksheet and submit to the grantee prior to contract award.

(Grantee may establish alternative methods of compliance equivalent to or more stringent than the above.)

MINORITY/WOMEN BUSINESS ENTERPRISE 00320-2

MINORITY, WOMEN’S AND SMALL RURAL BUSINESS ENTERPRISE WORKSHEET

Grant Applicant: Project No.:

Contractor/Engineer:

Address:

Contact Person: Telephone No.:

Amount of Contract: MBE Percentage: WBE Percentage:

1. MBE Subcontractor: WBE:

Address:

Contact Person: Telephone No.:

Amount of Subcontract:

Scope of Work:

2. MBE Subcontractor: WBE:

Address:

Contact Person: Telephone No.:

3. MBE Subcontractor: WBE:

Contact Person: Telephone No.:

4. MBE Subcontractor: WBE:

Contact Person: Telephone No.:

MINORITY/WOMEN BUSINESS ENTERPRISE 00320-3

5. MBE Subcontractor: WBE:

Contact Person: Telephone No.:

6. MBE Subcontractor: WBE:

Contact Person: Telephone No.:

Comments:

Prepared By Telephone No. Date

GUIDANCE FOR MINORITIY/WOMEN’S BUSINESS ENTERPRISE REQUIREMENT 00321-1

GUIDANCE FOR MINORITY BUSINESS ENTERPRISE AND WOMEN’S BUSINESS ENTERPRISE

REQUIREMENT OF 40 CFR 31.36(e)

I. PURPOSE

This guidance is to assist States, EPA assistance recipients, prime contractors, consultants, minority business owners and women’s business owners in complying with EPA’s Minority Business Enterprise (MBE) and Women’s Business Enterprise (WBE) requirements in the Agency’s procurement regulations, 40 CFR Part 31. This guidance provides suggestions for carrying out the affirmative steps included in EPA procurement regulations. Also included is a description of activities to be undertaken by EPA or delegated States, as well as suggestions for MBE/WBEs to take in pursuing opportunities for work in EPA-funded projects.

II. DEFINITIONS

A. Minority Business Enterprise (MBE): A minority business enterprise is a business which is

1. certified as socially and economically disadvantaged by the Small Business Administration;

2. certified as a minority business enterprise by a State or Federal agency; or

3. an independent business concern which is at least 51 percent owned and controlled (as defined below) by minority group member(s). A minority group member is an individual who is a citizen of the United States and one of the following:

a. Black American

b. Hispanic American (with origins form Puerto Rio, Mexico, Cuba, South or Central

America)

c. Native American (American Indian, Eskimo, Aleut, native Hawaiian)

d. Asian-Pacific American (with origins from Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the US Trust Territories of the Pacific, Northern Marianas, Laos, Cambodia, Taiwan or the Indian Subcontinent)

B. Women’s Business Enterprise (WBE): A women’s business enterprise is a business which is certified as such by a

State or Federal agency, or which meets the following definition:

A women’s business enterprise is an independent business concern which is at least 51 percent owned by a woman or women who also control and operate it. Determination of whether a business is a least 51 percent owned by a woman or women shall be made without regard to community property laws. For example, an otherwise qualified WBE which is 51 percent owned by a married woman in a community state will not be disqualified because her husband has a 50 percent interest in her share. Similarly, a business that is 51 percent owned by a married man and 49 percent owned by an unmarried woman will not become a qualified WBE by virtue of his wife’s 50 percent interest in his share of the business.

C. Ownership and Control:

1. The minority of women’s ownership’s interest in the firm must be real, substantial and continuing. Such interest may include:

a. risk of loss/share of profit commensurate with the proportional ownership; and

b. receipt of the customary incidents of ownership, such as salary and/or intangible benefits.

2. A minority or woman owner must have and exercise the authority to independently control the business.

The minority or woman owner need not be continually present to be deemed in control. Characteristics of control may include:

a. authority to sign contacts;

b. making decisions in price negotiations;

c. incurring liabilities for the firm;

d. making final staffing decisions;

GUIDANCE FOR MINORITIY/WOMEN’S BUSINESS ENTERPRISE REQUIREMENT 00321-2

e. policy-making; and

f. making general company management decisions.

3. Only those firms performing a useful business function according to custom and practice in the industry are qualified as MBEs or WBEs. Acting merely as a passive conduit of funds to some other, non-minority firm where such activity is unnecessary to accomplish the project the project does not constitute a “useful business function according to custom and practice in the industry.”

D. Recipient: A party receiving federal financial assistance under an EPA program pursuant to a grant or cooperative agreement.

E. Project: The scope of work from which a cooperative agreement, grant or grant amendment is awarded.

F. Bidder: A party seeking to obtain a contract with a recipient through a competitive, advertised, sealed bid process.

G. Offeror: A party seeking to obtain a contract with a recipient through a negotiated procurement process.

III. RESPONSIBILITIES

A. Headquarters.

1. The office in charge of the assistance program (program office) has primary responsibility for implementation of the MBE/WBE program, in cooperation with the Office of Small and Disadvantaged Business Utilization (OSDBU).

2. OSBDU is responsible for serving as the Agency focal point for inquiries on the MBE/WBE program, providing explanation of the program and guidance to MBEs and WBEs interested in working on EPA funded projects.

B. Regional Responsibilities.

1. Provide guidance and advice to recipients as requested.

2. Maintain lists of those MBE and WBE firms which have participated in EPA funded projects. The

Region may also add MBEs and WBEs requesting to be included on source lists. Such lists are for information purposes only, and shall carry a clear and prominent statement that the firms listed are neither endorsed nor guaranteed by EPA as bona fide MBE/WBEs. It is not necessary to be on any list in order to qualify as a bona fide MBE/WBE.

3. Monitor recipients for compliance with MBE/WBE requirements and for determining levels of MBE/WBE participation.

IV. RECIPIENT RESPONSIBILITIES

A. The recipient shall take affirmative steps to contract with MBEs and WBEs and ensure that its contractors and consultants take affirmative steps to contract with MBEs and WBEs during all phases of work funded or to be funded under an EPA assistance agreement. The recipient’s affirmative steps as defined in EPA procurement regulations are the following:

1. When feasible, dividing the total work to be contracted into smaller tasks in the solicitation documents to permit maximum MBE/WBE participation.

2. Placing qualified MBEs and WBEs on solicitation lists of EPA Regional Offices and appropriate minority/women’s business associations and agencies.

3. Assuring that MBEs and WBEs are solicited whenever they are potential sources of service and supplies, for example, by:

a. Holding pre-bid conferences, with interested MBEs and WBEs in attendance when possible, to highlight the requirements of this program to prospective bidders;

GUIDANCE FOR MINORITIY/WOMEN’S BUSINESS ENTERPRISE REQUIREMENT 00321-3

b. Including this MBE/WBE interim guidance in requests for proposals (RFP) and invitations for bid (IFB);

c. Publishing announcements of MBE/WBE opportunities for work on EPA funded projects;

d. Developing a source list of MBE/WBEs and providing its list to prospective bidders/offerors;

4. The recipient may wish to engage a MBE/WBE liaison to compile the list.

5. The recipient may wish to use available lists such as those of the EPA Regional Office, adjacent municipalities, appropriate minority/women associations. Names of these agencies with address and phone number should also be included on the recipient’s source list.

a. Providing necessary and appropriate liaison services between MBE/ WBEs and prospective bidders/offerors. (Liaison service should not be delegated to consultants where a potential for conflict of interest exists.)

6. When project requirements permit, establishing delivery schedules which encourage participation of MBE/WBEs.

7. Using the services and assistance of the Small Business Administration (SBA), the Minority

Business Development Agency (MBDA), and other federal, State and local agencies when appropriate.

B. Unless otherwise provided in the specifications, compliance with the MBE/WBE requirement in the regulations is a matter of bidder/offeror responsibility.

C. The recipient is responsible for monitoring work in progress to ensure that MBE and WBE subcontractors and joint venturers are actually participating in the performance of the subcontract or joint venture contract and to insure that the consultant/contractor is fulfilling its obligations with respect to MBE/WBE requirements under the contract.

D. As part of the documentation required under 40 CFR 31.36(b)(9), the recipient shall maintain and update records of MBE/WBE participation and supply data to the delegated State when requested. Such records may include:

1. Name of MBE/WBEs being utilized;

2. Work designated to be performed by MBE/WBE;

3. Dollar value of that work;

4. Portion of project being performed by MBEs and WBEs.

V. BIDDER AND OFFEROR RESPONSIBILITIES

A. Affirmative Steps: Activities during preparation of bids and offers. Bidders/offerors shall take affirmative steps in compliance with the regulations, prior to submission of bids or closing date for receipt of initial offers, to encourage participation in projects by MBEs and WBEs. Such efforts include:

1. When feasible, segmenting total work requirements to permit maximum MBE/WBE participation.

2. Assuring the MBEs and WBEs are solicited whenever they are potential sources of goods or services. This step may include:

a. Sending letters or making other personal contacts with MBEs and WBEs, (e.g. those whose names appear on lists prepared by EPA or the recipient and other MBE/WBEs known to the bidder/offeror).

MBEs and WBEs should be contacted when other potential subcontractors are contacted, within reasonable time prior to bid submission or closing date for receipt of initial offers. Those letters or other contacts should communicate the following:

1) Specific description of the work to be subcontracted;

2) How and where to obtain a copy of plans and specifications or other detailed information needed to prepare a detailed price quotation;

3) Date the quotation is due the bidder/offeror;

4) Name, address, and phone number of the person in the bidder/offeror’s firm whom the prospective

MBE/WBE subcontractor should contact for additional information.

GUIDANCE FOR MINORITIY/WOMEN’S BUSINESS ENTERPRISE REQUIREMENT 00321-4

b. Sending letters or making other personal contacts with local, State, federal and private agencies and

MBE/WBE associations relevant to the project. Such contacts should provide the same information provided in the direct contacts to MBE/WBE firms.

3. Where feasible, establishing delivery schedules which will encourage participation by MBEs and WBEs.

B. Bidders/offerors must demonstrate compliance with the MBE/WBE requirements in order to be deemed responsible. Demonstration of compliance may include the following information, however the recipient may specify other methods of demonstrating compliance:

1. Names, addresses and phone numbers of MBE/WBEs expected to perform work.

2. Work to be performed by the MBEs and WBEs.

3. Aggregate dollar amount of work to be performed by MBEs and WBEs, showing aggregate to

MBEs and aggregate to WBEs separately.

4. Description of contacts to MBE and WBE organizations, agencies and associations which service

MBEs/WBEs, including names of organizations, agencies and associations and dates of contact.

5. Description of contacts to MBEs and WBEs, including number of contacts, fields, (i.e. equipment or material supplier, excavators, transport serviced, electrical subcontractors, plumbers, etc.) and dates of contacts.

C. Successful bidders/offerors should take reasonable affirmative steps to subcontract with MBEs and WBEs whenever additional subcontracting opportunities arise during the performance of the contract.

VI. MBE AND WBE RESPONSIBILITIES

MBEs and WBEs are responsible for promoting themselves and taking the initiative to obtain contracts and subcontracts, and for encouraging joint venture arrangements. MBEs/WBEs interested in working on EPA funded projects are strongly encouraged to take the following steps:

A. Submit information to the recipients to identify status as a MBE/WBE.

B. Become certified as MBE/WBE under available State of federal agency procedures.

C. Contact federal, State, and local MBE/WBE liaison offices to obtain information on potential jobs.

D. Provide capability statements to State agencies, recipients, consulting engineers, and contractors, stating type(s) of work performed by the firm, size of job that the firm can handle, bonding information, and any special skills.

E. Make every effort to establish contacts and relationships with contractors for potential future business, including attending pre-bid conferences and subscribing to industry and trade journals.

F. Contact EPA Regional offices or appropriate State offices to obtain information on planned EPA funded projects.

G. Respond promptly to solicitation requests.

VII. REMEDIES FFOR NONCOMPLIANCE

A. Protests. A bidder/offeror for EPA funded work or MBE/WBE with an adversely affected direct financial interest may file a bid protest with the recipient pursuant to EPA procurement regulations 40 CFR 31.36(b)(12).

These procedures are available to protest alleged violation of federal MBE/WBE requirements and may not be used to enforce local or State MBE/WBE requirements.

B. Upon a finding by EPA that a recipient, bidder/offeror, consultant, contractor or subcontractor has not complied with the MBE/WBE requirements of EPA regulations, EPA may invoke any and all sanctions and remedies specified in EPA regulations.

VIII. STATE OR LOCAL LAW

Nothing in this program prevents a State or recipient from applying more stringent MBE/WBE requirements or procurement obligations which pertain to bid responsiveness or percentage of MBE and WBE participation.

CERTIFICATION OF NONSEGREGATED FACILITIES 00330-1

US ENVIRONMENTAL PROTECTION AGENCY

CERTIFICATION OF NONSEGREGATED FACILITIES

(Applicable to contracts, subcontracts, and agreements with the applicants who are themselves performing Federally assisted construction contracts, exceeding $10,000, which are not exempt from the provisions of the Equal Opportunity Clause.)

By the submission of this bid, the bidder, offeror, applicant, or subcontractor certifies that he does not maintain or provide for his employees any segregated facilities at any of his establishments, and that he does not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. He certifies further that he will not maintain or provide for his employees any segregated facilities at any of his establishments, and that he will not permit his employees to perform their services at any location, under his control, where segregated facilities are maintained. The bidder, offeror, applicant, or subcontractor agrees that a breach of this certification is a violation of the Equal Opportunity clause in this contract. As used in this certification, the term “segregated facilities” means any waiting rooms, work areas, rest rooms and washrooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees which are segregated by explicit directive or are in fact segregated on the basis of race, creed, color, or national origin, because of habit, local custom, or otherwise. He further agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of the Equal Opportunity clause; that he will retain such certifications in his files; and that he will forward the following notice to such proposed subcontractors (except where the proposed subcontractors have submitted identical certifications for specific time periods):

NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR CERTIFICATION OF NONSEGREGATED FACILITIES

A Certification of Non-segregated Facilities, as required by the May 9, 1967 order (33 F.R. 7808, May 28, 1968) on Elimination of Segregated Facilities, by the Secretary of Labor, must be submitted prior to the award of a subcontract exceeding $10,000 which is not exempt from the provisions of the Equal Opportunity clause. The certification may be submitted either for each subcontract or for all subcontracts during a period (i.e., quarterly, semiannually, or annually).

Signature Date

Name and Title of Signer (Please Type)

NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001

EPA-7 5720-4.2 (6/2/77)

CERTIFICATION REGARDING LOBBYING 00340-1

Recipient Certification - Anti-Lobbying Act of 1990 US Department of the Interior

Certification Regarding Lobbying

This certification is required by Section 1352, title 31, US Code, entitled “Limitation on use of appropriated funds to influence certain Federal contracting and financial transactions.”

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)

Certification for Contracts, Grants, Loans, and 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 person for influencing or attempting to influence an officer or employee of any agency, a Member Congress, and officer or employee of Congress, or an employee of a Member of Congress in 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 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 accordance with its instructions.

3) The undersigned shall require that 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 accordingly.

This certification is a material representation of fact upon which reliance was placed when this 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, US 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.

Signature Date

CERTIFICATION REGARDING LOBBYING 00340-2

Instructions for Certification

1. This certification and a disclosure form should be filed by each person as required, with each submission that initiates agency consideration of such person for: ( 1 ) award of a Federal contract, grant, or cooperative agreement exceeding $100,000 or (2) an award of a Federal loan or a commitment providing for the United States to insure or guarantee a loan exceeding $ 150,000.

2. This certification and a disclosure form should be filed by each person as required, upon receipt by such person of(1) a Federal contract, grant, or cooperative agreement exceeding $100,000; or (2) a loan or a commitment providing for the United States to insure or guarantee a loan exceeding $150,000, unless such person previously filed a certification, and a disclosure form, if required, at the time agency consideration was initiated.

3. Any person who requests or receives from a person referred to in paragraphs (1) and (2) above: (1) a subcontract exceeding $100,000 at any tier under a Federal contract; (2) a subgrant, contract, or subcontract exceeding $100,000 at any tier under a Federal grant (3) a contract or subcontract exceeding $100,000 at any tier under a Federal loan exceeding $150,000; or, (4) a contract or subcontract exceeding $100,000 at any tier under a Federal cooperative agreement, shall file a certification, and a disclosure form, as required, to the next tier above.

4. All disclosure forms, but not certifications, shall be forwarded from tier to tier until received by the person referred to in paragraphs (1) or (2) above. That Person shall forward all disclosure forms to the appropriate Bureau/Office within the Department of the Interior.

5. Any certification or disclosure form flied under paragraph (4) above shall be treated as a material representation of fact upon which all receiving tiers shall rely. All liability arising from an erroneous representation shall be borne solely by the tier filing that representation and shall not be shared by any tier to which the erroneous representation is forwarded. Submitting an erroneous or disclosure constitutes a failure to file the required certification or disclosure, respectively. If a person fails to file a required certification or disclosure, the United States may pursue all available remedies, including those authorized by Section 1352, title 31. US Code.

DISCLOSURE OF LOBBYING ACTIVITIES 00350-1

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subwardee or prime federal recipient, at the initiation or receipt of a covered federal action, or a material change to a previous filing, pursuant to title 31 U.S.C.

section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity 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 a covered federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered federal action.

2. Identify the status of the covered federal action.

3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered federal action.

4. Enter the full name, address, city, state and zip code of the reporting entity. Include congressional district, if known.

Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee (e.g., the first subawardee of the prime is the first tier).

Subawards include, but are not limited to, subcontracts, subgrants and contract awards under grants.

5. If the organization filling the report in Item 4 checks “Subawardee,” then enter the full name, address, city, state and zip code of the prime federal recipient. Include congressional district, if known.

6. Enter the name of the federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example, Department of Transportation, United States Coast Guard.

7. Enter the federal program name or description for the covered federal action (Item 1). If known, enter the full

Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate federal identifying number available for the federal action identified in Item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement number; the contract, grant or loan award number; the application/proposal control number assigned by the federal agency). Include prefixes (e.g., “RFP-DE-90-001”).

9. For a covered federal action where there has been an award or loan commitment by the federal agency, enter the federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5.

10. a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in Item 4 to influence the covered federal action.

b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter last name, first name and middle initial (MI).

11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.

DISCLOSURE OF LOBBYING ACTIVITIES 00350-2

12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment.

13. Check the appropriate box(es). Check all boxes that apply. If other, specify name.

14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with federal officials. Identify the federal official(s) or employee(s) contacted or the officer(s), employee(s), or member(s) of Congress that were contacted.

15. Check whether or not a SF-LLL-A Continuation Sheet(s) is/are attached.

16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

Public reporting burden for this collection at of intermission is estimated to average 30 minutes per response. Including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project, (0348-0045), Washington DC 20503

DISCLOSURE OF LOBBYING ACTIVITIES 00350-3

(See reverse for public burden disclosure)

1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

a. Bid/Offer/Application

b. Initial Award

c. Post-award

a. Initial/Filing

b. material change

For Material Change Only:

year quarter date of last report

4. Name and Address of Reporting Entity:

Prime Subawardee Tier______, if known

Congressional District, if known

5. If Reporting Entity in No. 4 is Subawardee, enter name and Address of Prime:

Congressional District, if known

6. Federal Department/Agency: 7. Federal Program Name/Description:

CFDA Number, if applicable

8. Federal Action Number, if known: 9. Award Amount, if known:

10. a. Name and Address of Lobbying Entity:

(if individual, last name, first name, MI)

(Attach Continuation Sheet(s) SF-LLL-A if Necessary)

b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI)

11. Amount of Payment (check all that apply):

$____________ actual planned

12. Form of Payment (check all that apply):

a. cash

b. in-kind; specify: nature________________ value _________________

13. Type of Payment (check all that apply):

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other; specify: ______________________

14. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contracted, for Payment indicated in item 11:

(Attach Continuation Sheet(s) SF-LLL-A if Necessary)

15. Continuation Sheet(s) SF-LLL-A attached: Yes No

DISCLOSURE OF LOBBYING ACTIVITIES 00350-4

16: The information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of facts upon which evidence was placed by the above when this transaction was made or started into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the congress semi-annually and will be available for public inspection. Any person which fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature:

Print Name:

Title:

For Federal Use Only: Authorized for local reproduction Standard Form-LLL

Telephone No.: Date:

DISCLOSURE OF LOBBYING ACTIVITIES 00350-5

NONDISCRIMINATION IN EMPLOYMENT 00360-1

NONDISCRIMINATION IN EMPLOYMENT

(Instructions for Bidders)

By the submission of its bid, each bidder acknowledges that he understands and agrees to be bound by the equal opportunity requirements of EPA regulations (40 CFR Part 8, particularly Section 8.4(b)), which shall be applicable throughout the performance of work under any contract awarded pursuant to this solicitation. Each bidder agrees that if awarded a contract, it will similarly bind contractually each subcontractor. In implementation of the foregoing policies, each bidder further understands and agrees that if awarded a contract, it must engage in affirmative action directed at promoting and ensuring equal employment opportunity in the workforce used under the contract (and that it must require contractually the same effort of all subcontractors whose subcontracts exceed $ 10,000). The bidder understands and agrees that “affirmative action” as used herein Shall constitute a good faith effort to achieve and maintain that amount of minority employment in the on-site workforce used on the project which corresponds, for each trade used, to the minority population in the serving labor market area from which workers are reasonably available for hire for the project.