FEMA Form 112-0-3C, Certifications Regarding Lobbying; Debarment, Suspension and Other Responsibility Matters; and Drug-Free Workplace Requirements

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS

O.M.B. No. 1660-0025
Expires November 30, 2013

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 1.7 hours per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required
to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send
comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 1800 South Bell Street, Arlington, VA 20598-3005 Paperwork Reduction Project (1660-0025).
NOTE: Do not send your completed form to this address.
Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Applicants should also review the
instructions for certification included in the regulations before completing this form. Signature of this form provides for compliance with certification
requirements under 44 CFR Part 18, "New Restrictions on Lobbying" and 28 CFR Part 17, "Government-wide Debarment and Suspension (Nonprocurement)
and Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material representation of fact upon which
reliance will be placed when the Federal Emergency Management Agency (FEMA) determines to award the transaction, grant, or cooperative agreement.
1. LOBBYING
As required by section 1352, Title 31 of the U.S. Code, and implemented
at 44 CFR Part 18, for persons entering into a grant or cooperating
agreement over $ 100,000, as defined at 44 CFR Part 18, the applicant
certifies that:
(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 making of any Federal grant, the entering into of any
cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal grant or cooperative
agreement.
(b) If any other funds than Federal appropriated funds have been paid or will be

paid to any other person for influencing or attempting to influence an officer
or employee of any agency, a member of Congress, an officer or an
employee of Congress, or employee of a member of Congress in
connection with this Federal Grant or cooperative agreement, the
undersigned shall complete and submit Stand Form-LLL, "Disclosure of
Lobbying Activities," in accordance with its instructions.
c) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers (including
subgrants, contracts under grants and cooperative agreements, and
subcontracts) and that all subrecipients shall certify and disclose
accordingly.
Standard Form-LLL "Disclosure of Lobbying Activities" attached

(c) Are not presently indicted for otherwise criminally or civilly charged by a
governmental 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 had one or
more public transactions (Federal, State, or local) terminated for cause of
default; and
B. Where the applicant is unable to certify to any of the statements in this
certification, he or she shall attach an explanation to this application.
3. DRUG-FREE WORKPLACE
(GRANTEE OTHER THAN INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at
44 CFR Part 17, Subpart F, for grantees, as defined at 44 CFR Part 17.615
and 17.620A. The applicant certifies that it will continue to provide a drug-free
workplace 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 an on-going drug free awareness program to inform
employees about-

(This form must be attached to certification if nonappropriated funds are to
be used to influence activities.)

(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;

2. DEBARMENT,SUSPENSION, AND OTHER RESPONSIBILITY
MATTERS (DIRECT RECIPIENT)

(3) Any available drug counseling, rehabilitation, and
employee assistance programs; and

As required by Executive Order 12549, Debarment and Suspension, and
implemented at 44 CFR Part 67, for prospective participants in primary
covered transactions, as defined at 44 CFR Part 17, Section 17.510-A.
A. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment,
declared ineligible, sentenced to a denial of Federal benefits by a State or
Federal court, or voluntarily excluded from covered transactions by any
Federal department or agency;
(b) Have not within a three-year period preceding this application been
convicted of a or had a civilian judgment rendered against them for
commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or perform a public 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;
FEMA Form 112-0-3C (11/2010)

(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 to be given a copy of the statement required by
paragraph (a);
(d) Notifying the employee in the statement required by paragraph (a) that,
as a condition of employment under the grant, the employee will-

PREVIOUS EDITION OBSOLETE

(1) Abide by the term of the statement; and
(2) Notify the employee in writing of his or her conviction for a
violation of a criminal drug statute occurring ion the workplace no
later than five calendar days after such convictions;

(e) Notifying the agency, in writing, within 10 calendar days after receiving
notice under subparagraph (d)(2) from an employee or otherwise receiving
actual notice of such conviction. Employers of convicted employees must
provide notice, including position, title, to the applicable FEMA awarding
office, i.e., regional office or FEMA office.

Place of Performance (Street address, City, County, State, Zip code)

(f) Taking one of the following actions, within 30 calendar days of receiving
notice under subparagraph (d)(2), with respect to any employee who is
convicted(1) Taking appropriate personnel action against such an employee,
up to and including termination, consistent with the requirements of
the Rehabilitation act of 1973, as amended; or
(2) Requiring such an 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).
B. The grantee may insert in the space provided below the site(s) for the
performance of work done in connection with the specific grant:

There are workplaces on file that are not identified
Sections 17.630 of the regulations provide that a grantee that is a
State may elect to make one certification in each Federal fiscal
year. A copy of which should be included with each application for
FEMA funding. States and State agencies may elect to use a state
wide certification.