Annex G Awardee Certifications and Disclosures

Annex G

ANNEX G
(Awardee Acronym)
(Grant #)

Awardee Certifications and Disclosures
This Annex sets forth certifications, assurances, and representations given in consideration of
and for the purpose of obtaining the IAF Award. The Awardee must complete all certifications in
this section and return them to the IAF by [deadline]. It is the Awardee’s responsibility to update
these certifications and disclosures within fourteen (14) days of any changes to the Awardee’s
ability to make the representation, including if changes are made to individuals holding positions
subject to the representation. The Awardee recognizes and agrees that such Federal financial
assistance will be extended in reliance on the representations and agreements made in this
Annex G, and that the United States will have the right to terminate the Award, seek judicial
enforcement, or take any other action under the Award terms if the Awardee submits a false
representation.

List of Certifications and Disclosures:
Certifications and Disclosures Applicable to All Awards
Annex G1: Certification Regarding Lobbying
Annex G2: Certification of Drug Free Workplace
Annex G3: Certification Regarding Support to Terrorists, Implementing Executive Order 13224
Annex G4: Conflicts of Interest Disclosure
Annex G5: Major Non-Profit Organization Certification
Annex G6: Assurance of Compliance with Laws and Regulations Governing Non-discrimination
in Federally Assisted Programs
Certifications and Disclosures Applicable to Selected Awards
Annex G7: Certification Regarding Trafficking in Persons
Instructions for Annexes G8-G9
Annex G8: Key Individual(s) Narcotics Offenses and Drug Trafficking Certification
Annex G9: Covered Participant Narcotics Offenses and Drug Trafficking Certification

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ANNEX G
Awardee ACRONYM
XX-XXX

Certifications and Disclosures Applicable to All Awards

Annex G1: Certification Regarding Lobbying
In accordance with 31 USC 1352, the Awardee may not use US federal appropriated funds to
lobby and must report any non-US federal appropriated funds that it used to lobby in connection
with this Award. If the Award is for $100,000USD or more, the Awardee must also submit this
certification and pass-through the provisions of this Award in subgrants and contracts related to
this Award.
The Awardee certifies to the best of their knowledge and belief that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or employee of
an agency, a Member of the U.S. Congress, an officer or employee of the U.S. Congress, or an
employee of a Member of the U.S. Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the entering into of
any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any U.S. agency, a
Member of the U.S. Congress, an officer or employee of the U.S. Congress, or an employee of
a Member of the U.S. Congress in connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall inform the IAF. The IAF will provide the Awardee
with the Standard Form-LLL, “Disclosure Form to Report Lobbying,” and the Awardee will
complete the form in accordance with its instructions.
3) The Awardee shall require that the language of this certification be included in the award
documents for:
(A) If this Award is a grant: subgrants and contracts in connection with this Award.
(B) If this Award is a cooperative agreement: contracts in connection with this Award.

________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).

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ANNEX G
Awardee ACRONYM
XX-XXX

Annex G2: Certification of Drug Free Workplace
In accordance with the Drug Free Workplace Act of 1988 and 22 CFR 1008, the Awardee must
certify that it will maintain a drug free workplace, or in the case of an individual, certify that his or
her conduct of Award activity will be drug free. This requirement applies to all awardees of
United States Government foreign assistance programs to the extent that making such drug free
certifications are consistent with the laws or regulations of the countries in which the awardees
carry out their award activities.
The Awardee certifies that it will 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 (illegal drugs) is prohibited in
the Awardee'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:
(i)
the dangers of drug abuse in the workplace;
(ii)
the Awardee's policy of maintaining a drug free workplace;
(iii)
any available drug counseling, rehabilitation, and employee assistance programs;
and
(iv)
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
Award 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:
(i)
abide by the terms of the statement; and
(ii)
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 IAF within ten days after receiving the notice under subparagraph (d)(2)
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), with respect to any employee who is so convicted:
(i) taking appropriate personnel action against such an employee, up to and including
termination; or
(ii) requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a national or local health, law
enforcement, or other appropriate agency;

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ANNEX G
Awardee ACRONYM
XX-XXX

(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).

________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).

NOTICE: The certification is a material representation of fact upon which the IAF relied
in deciding this Award. If it is later determined that the Awardee knowingly rendered a
false certification, or otherwise violates the requirements of the DrugFree Workplace Act,
the IAF may take action authorized under the DrugFree Workplace Act, including
suspension or termination of the Agreement. A suspension of payments, termination, or
suspension or debarment proceeding subject to this subsection shall be conducted in
accordance with applicable law, including Executive Order 12549 or any superseding
executive order and any regulations prescribed to implement the law or executive order.
An Awardee debarred by a final decision under this subsection is ineligible for award of
a grant by a Federal agency, and for participation in a future grant by a Federal agency,
for a period specified in the decision, not to exceed 5 years.

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ANNEX G
Awardee ACRONYM
XX-XXX

Annex G3: Certification Regarding Support to Terrorists, Implementing
Executive Order 13224
In accordance with Executive Order 13224, the Awardee must certify that, as of the date on
which the award application was submitted to the IAF, the Awardee did not, within the previous
three years, knowingly engage in transactions with, or provide material support or resources to,
any individual or entity who was, at the time, subject to sanctions administered by the Office of
Foreign Assets Control (OFAC) 1 within the U.S. Department of Treasury pursuant to the Global
Terrorism Sanctions Regulations (31 CFR 594), and the Foreign Terrorist Organizations
Sanctions Regulations (31 CFR 597), or sanctions established by the United Nations Security
Council, collectively, “U.S. or U.N. sanctions” 2.
This certification includes express terms and conditions of the Award Terms and Conditions
(Annex B), and any violation of it will be grounds for unilateral termination of the Agreement by
the IAF. This certification does not preclude any other remedy available to the IAF.
For purpose of this certification:
(a) Material support and resources” means currency or monetary instruments or financial
securities, financial services, lodging, training, expert advice or assistance, safehouses,
false documentation or identification, communications equipment, facilities, weapons,
lethal substances, explosives, personnel, transportation, and other physical assets,
except medicine or religious materials.
(i) “Training" means instruction or teaching designed to impart a specific skill, as opposed
to general knowledge.
(ii) Expert advice or assistance" means advice or assistance derived from scientific,
technical, or other specialized knowledge.
(b) “Entity” means a partnership, association, corporation, or other organization, group, or
subgroup.
________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).

1
2

Please refer to https://ofac.treasury.gov/sanctions-list-service.
Please refer to https://scsanctions.un.org/search/.

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ANNEX G
Awardee ACRONYM
XX-XXX

Annex G4: Conflicts of Interest Disclosure
Per the Award Terms and Conditions (Annex B) Clause VI, the Awardee must disclose any
actual, potential, or perceived personal or organizational conflicts of interest.
The Awardee must fill out the following disclosure and return it with the first disbursement
request. If a new conflict arises, the Awardee must use this form to disclose the conflict and the
Awardee’s proposed resolution before taking action on the conflict if possible. If at any point the
Awardee becomes aware of a previously unreported conflict of interest, this form must be
resubmitted as soon as possible. Any conflicts of interest and proposed resolutions must be
reviewed by IAF’s Office of General Counsel before a disbursement can occur. IAF reserves the
right to deny a cost associated with a conflict that was not reviewed by the IAF prior to the
Awardee taking action on the conflict.
In your disclosure describe any relationships or circumstances that could contribute to a conflict
of interest and the Awardee’s approach for resolving the conflict. Please include the name of all
relevant entities and their relationship to each other, the description of the potential conflict of
interest, and the entity’s proposed action including any mitigation measures. If there are multiple
potential conflicts, please number them and describe them separately. Please attach your
organization’s Conflict of Interest Policy as well as any other relevant document such as your
organization’s by-laws or organization chart.
Example 1: Project Coordinator Jane Doe supervises her nephew, John Doe who is the
accountant. The Project Coordinator was part of the three person panel who hired the
nephew for this project. Nephew is qualified for the role and the only other applicants
were deemed unqualified. Our organization proposes removing the Project Coordinator
as supervisor of her nephew who will instead be supervised by the technical advisor.
Example 2: The Secretary of our Board of Directors, Juanita Lopez, is also the director
of the organization ABC, who is applying for a subaward from our organization under the
project using IAF funds. We propose removing the Secretary from any Board decision
having to do with the IAF project including decisions on subawards.

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ANNEX G
Awardee ACRONYM
XX-XXX

If there are no actual, potential, or perceived conflicts of interest, please check the box certifying
that there are none, below.
●

By checking this box I certify that there are currently no actual, potential, or perceived
conflicts of interest as defined by the Award Terms and Conditions (Annex B).
OR

●

This is notice to IAF that the following actual, potential, or perceived conflicts of interest
exist and that the Awardee proposes the included resolution:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

__________________________
Authorized Representative Signature

_________________

__________________________
Name

________________________
Title

on behalf of _____________________ (Awardee name).

Date

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ANNEX G
Awardee ACRONYM
XX-XXX

Annex G5: Major Non-Profit Organization Certification
In accordance with 2 CFR 200.414, Major Nonprofit Organizations must provide IAF with
additional information. Complete Part A, and if directed to, Part B to determine if this
certification is required.
(A) Per 2 CFR 200.1 a Nonprofit Organization is a corporation, trust, association,
cooperative, or other organization, not including an Institute of Higher Education 3, that:
(1) Is operated primarily for scientific, educational, service, charitable, or similar
purposes in the public interest; (2) Is not organized primarily for profit; and (3) Uses net
proceeds to maintain, improve, or expand the operations of the organization.
________
________

Awardee is not a Nonprofit Organization under this definition (Part I is
complete, move to Part II)
Awardee is a Nonprofit Organization under this definition (complete
subpart (B) of this Part)

(B) Per 2 CFR 200.414(a), Major Nonprofit Organizations are those which receive more than
$10 million dollars in direct Federal funding. Based on above, please mark as
appropriate:
________
________

Awardee is not a major nonprofit organization under this definition.
(Annex G4 is complete, move to Annex G5)
Awardee is a Major Nonprofit Organization under this definition and
therefore must comply with the requirement of 2 CFR 200.415 to provide
the IAF with a cost allocation plan or indirect (F&A) cost rate proposal
F&A breakdown. (Sign the below certification)

I certify that the Awardee will comply with the requirement of 2 CFR 200.415 to provide the IAF
with a cost allocation plan or indirect (F&A) cost rate proposal F&A breakdown.
________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).

3

Institute of Higher Education means an educational institution in any State of the United States that
meets the requirements of 20 U.S.C. 1001.

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ANNEX G
Awardee ACRONYM
XX-XXX

Annex G6: Assurance of Compliance with Laws and Regulations Governing Nondiscrimination in Federally Assisted Programs
United States organizations and Awards taking place within the United States are subject to
additional laws and regulations. Answer Part A to determine if this certification is required.
(A) Is the Awardee a Non-U.S. organization AND will any part of the award activities be
undertaken in the United States? (If awardee is a non-US organization and the entire
award will be undertaken outside of the United States, answer NO.)
☐ NO (Annex G5 is complete, move to Annex G6)
☐ YES (Awardee must sign the below certification before moving to Annex G6)

If “YES”, the Awardee must sign the following certification:
I hereby assure that no person in the United States will, on the bases set forth below, be
excluded from participation in, be denied the benefits of, or be otherwise subjected to
discrimination under, any program or activity receiving financial assistance from the IAF, and
that Awardee will comply with the requirements of:
(1) Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352, 42 USC 2000-d), which prohibits
discrimination on the basis of race, color or national origin, in programs and activities receiving
Federal financial assistance;
(2) Section 504 of the Rehabilitation Act of 1973 (29 USC 794), which prohibits discrimination
on the basis of disability in programs and activities receiving Federal financial assistance;
(3) The Age Discrimination Act of 1975, as amended (Pub. L. 95-478), which prohibits
discrimination based on age in the delivery of services and benefits supported with Federal
funds;
(4) Title IX of the Education Amendments of 1972 (20 USC 1681, et seq.), which prohibits
discrimination on the basis of sex in education programs and activities receiving Federal
financial assistance (whether or not the programs or activities are offered or sponsored by an
educational institution); and
(5) Any IAF regulations implementing the above nondiscrimination laws, set forth in 22 CFR
1001-1009.
If the Awardee is an institution of higher education, the assurances given herein extend to
admission practices and to all other practices relating to the treatment of students or clients of
the institution, or relating to the opportunity to participate in the provision of services or other
benefits to such individuals, and must be applicable to the entire institution unless the recipient
establishes to the satisfaction of the IAF that the institution's practices in designated parts or

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ANNEX G
Awardee ACRONYM
XX-XXX

programs of the institution will in no way affect its practices in the program of the institution for
which financial assistance is sought, or the beneficiaries of, or participants in, such programs.
________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).

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ANNEX G
Awardee ACRONYM
XX-XXX

Certifications and Disclosures Applicable to Selected Awards

Annex G7: Certification Regarding Trafficking in Persons
In accordance with Title XVII of the National Defense Authorization Act, awards for services to
be performed outside the United States which exceed $500,000USD must not participate in
trafficking in persons. If the Award is for more than $500,000 and Award Activities will take place
outside of the United States, this certification must be completed prior to receiving an award.
This certification must also be submitted annually to the IAF during the term of the Award. You
do not need to complete this certification if your Award is less than $500,000, however if your
Award is amended to be for more than $500,000, you must submit this certification before that
amendment can be awarded and annually thereafter.
In accordance with Title XVII of the National Defense Authorization Act for Fiscal Year 2013, I
certify on behalf of Awardee that:
1. The Awardee has implemented a compliance plan 4 to prevent the prohibited activities
identified in Award Terms and Conditions (Annex B), Section XVIII Combating Trafficking in
Persons and is in compliance with that plan;
2. The Awardee has implemented procedures to prevent any activities described in Award
Terms and Conditions (Annex B), Section XVIII Combating Trafficking in Persons and to
monitor, detect, and terminate any contractor, subgrantee, employee, or other agent of the
Awardee engaging in any activities described in such section; and
3. To the best of the Awardee representative’s knowledge, neither the Awardee, nor any
employee, contractor, or subgrantee of the applicant/recipient, nor any agent of the Awardee or

4

The compliance plan must include, at a minimum, the following:
(i) An awareness program to inform recipient employees about the Government's policy prohibiting
trafficking-related activities described in paragraph (a) of this section, the activities prohibited, and the
actions that will be taken against the employee for violations. Additional information about Trafficking in
Persons and examples of awareness programs can be found at the website for the Department of State's
Office to Monitor and Combat Trafficking in Persons at http://www.state.gov/j/tip/.
(ii) A process for employees to report, without fear of retaliation, activity inconsistent with the policy
prohibiting trafficking in persons.
(iii) A recruitment and wage plan that only permits the use of recruitment companies with trained
employees, prohibits charging recruitment fees to the employees or potential employees and ensures that
wages meet applicable host-country legal requirements or explains any variance.
(iv) A housing plan, if the recipient, subrecipient, contractor, or subcontractor intends to provide or
arrange housing, that ensures that the housing meets host-country housing and safety standards.
(v) Procedures to prevent agents, subrecipients, contractors, or subcontractors at any tier and at any
dollar value from engaging in trafficking in persons, including activities in paragraph (a) of this section,
and to monitor, detect, and terminate any agents, subgrants, or subrecipient, contractor, or subcontractor
employees that have engaged in such activities.
2 C.F.R. 175.105(b)(5).

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ANNEX G
Awardee ACRONYM
XX-XXX

of such a contractor or subgrantee, is engaged in any of the activities described in Award Terms
and Conditions (Annex B), Section XIII Combating Trafficking in Persons.

________________________________
Authorized Representative Signature

_______________
Date

________________________________
Name

________________________
Title

signed on behalf of _____________________________________ (Awardee name).