State Programs - Debarment Certification form

STATE:___________________________

CERTIFICATIONS REGARDING: NONDISCRIMINATION; DEBARMENT AND
SUSPENSION; DRUG-FREE WORKPLACE; FEDERAL DEBT STATUS; AND
LOBBYING
1. Nondiscrimination
The authorized representative, on behalf of the State library administrative agency (SLAA),
certifies that the SLAA will comply with the following nondiscrimination statutes and their
implementing regulations:
(a) Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. § 2000 et seq.), which
prohibits discrimination on the basis of race, color, or national origin;
(b) Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 701 et seq.),
which prohibits discrimination on the basis of disability (note: IMLS applies the
regulations in 45 C.F.R part 1170 in determining compliance with § 504 as it applies to
recipients of Federal assistance);
(c) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§ 1681–83,
1685–86), which prohibits discrimination on the basis of sex in education programs; and
(d) the Age Discrimination in Employment Act of 1975, as amended (42 U.S.C. § 6101 et
seq.), which prohibits discrimination on the basis of age.
2. Debarment and Suspension
The SLAA shall comply with 2 C.F.R part 3185. The authorized representative, on behalf of the
SLAA, certifies to the best of his or her knowledge and belief that neither the SLAA nor any of its
principals for the Five Year Plan:
(a) Are presently excluded or disqualified;
(b) Have been convicted within the preceding three years of any of the offenses listed in 2
C.F.R. part 180.800(a) or had a civil judgment rendered against it or them for one of
those offenses within that time period;
(c) Are presently indicted for or otherwise criminally or civilly charged by a governmental
entity (Federal, State, or local) with commission of any of the offenses listed in 2 C.F.R.
part 180.800(a); or
(d) Have had one or more public transactions (Federal, State, or local) terminated within the
preceding three years for cause or default.
Where the SLAA is unable to certify to any of the statements in this certification, the authorized
representative shall attach an explanation to this form.
The SLAA, as a primary tier participant, is required to comply with 2 C.F.R. part 180 subpart C
(Responsibilities of Participants Regarding Transactions Doing Business with Other Persons) as
a condition of participation in the award. The SLAA is also required to communicate the
requirement to comply with 2 C.F.R. part 180 subpart C (Responsibilities of Participants

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Regarding Transactions Doing Business with Other Persons) to persons at the next lower tier
with whom the SLAA enters into covered transactions.
3. Drug-Free Workplace
The authorized representative, on behalf of the SLAA, certifies, as a condition of the award, that
the SLAA will or will continue to provide a drug-free workplace by complying with the
requirements in 2 C.F.R. part 3186 (Requirements for Drug-Free Workplace (Financial
Assistance)). In particular, the SLAA as the recipient must comply with drug-free workplace
requirements in subpart B of 2 C.F.R. part 3186, which adopts the Government-wide
implementation (2 C.F.R. part 182) of sections 5152-5158 of the Drug-Free Workplace Act of
1988 (P. L. 100-690, Title V, Subtitle D; 41 U.S.C. §§ 701-707).
This includes, but is not limited to: making a good faith effort, on a continuing basis, to maintain
a drug-free workplace; publishing a drug-free workplace statement; establishing a drug-free
awareness program for the SLAA’s employees; taking actions concerning employees who are
convicted of violating drug statutes in the workplace; and identifying (either at the time of
application or upon award, or in documents that the SLAA keeps on file in its offices) all known
workplaces under its Federal awards.
4. Federal Debt Status
The authorized representative, on behalf of the SLAA, certifies to the best of his or her
knowledge and belief that the SLAA is not delinquent in the repayment of any Federal debt.
5. Certification Regarding Lobbying Activities (Applies to Applicants Requesting Funds
in Excess of $100,000) (31 U.S.C. § 1352)
The authorized representative certifies, to the best of his or her knowledge and belief, that:
(a) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
authorized representative, to any person for influencing or attempting to influence an
officer or employee of an 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 Federal appropriated funds have been paid or will be paid to any
person (other than a regularly employed officer or employee of the applicant, as
provided in 31 U.S.C. § 1352)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 authorized representative shall complete and submit
Standard Form LLL, “Disclosure of Lobbying Activities,” in accordance with its
instructions.
(c) The authorized representative shall require that the language of this certification be
included in the award documents for all subawards at all tiers (including subcontracts,
subgrants, and contracts under grants, loans, and cooperative agreements) and that all
subrecipients shall certify and disclose accordingly.

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This certification is a material representation of fact upon which reliance is placed when the
transaction is made or entered into. Submission of this certification is a prerequisite for making
or entering into the transaction imposed by 31 U.S. C. § 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.

The undersigned further provides assurances that it will include, as applicable, the language of
the certifications in all subawards and that all subrecipients shall certify and disclose
accordingly.
As the duly authorized representative of the applicant, I hereby certify that the applicant will
comply with the above certifications.

Signature of Authorized Certifying Official

Print name and Title of Authorized Certifying Official

___________________________
Date

OMB No. 3137-0071; Expiration Date: 8/31/2013

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