FY16 LIBRARY ADDTL LSTA CERTIFICATIONSThe grantee shall comply with 2 CFR Part 3185. The undersigned, on behalf of the grantee, certifies to
the best of his or her knowledge and belief that neither the grantee nor any of its principals:
(a) Are presently excluded or disqualified;
N Have been convicted within the preceding three years of any of the offenses listed in 2 CFR
section I 80.800(a) or had a civil judgment rendered against you 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 CFR section 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 grantee is unable to certify to any of the statements in this certification, he or she shall
attach an explanation to this submission.
The grantee is required to communicate the requirement to comply with 2 CFR Part 180 Subpart C
(Responsibilities of Participants Regarding Transactions Doing Business With Other Persons) to persons
at the next lower tier with whom the grantee enters into covered transactions.
AS required by Section 1352, Title 31 of the United States Code, and implemented for persons entering
into a grant or cooperative agreement over $ 100,000, the grantee 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 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 a Federal contract, the making of a Federal grant, the making of a
Federal loan, the entering into of a cooperative agreement, or the extension, continuation, renewal,
amendment, or modification of a Federal contract, grant, loan, or cooperative agreement.
(b) If any funds other than appropriated Federal funds have been paid or will be paid to any person
(other than a regularly employed officer or employee of the grantee) 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 undersigned shall request, complete, and submit Standard 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 subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
page 1 of 2
3. FEDERAL DEBT STATUS
The undersigned, on behalf of the grantee, certifies to the best of his or her knowledge and belief that the
grantee is not delinquent in the repayment of any Federal debt.
RMLIFIEN tt WN R 131005MOM
As required by the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Education Amendments
of 1972, and the Age Discrimination in Employment Act of 1975, as implemented at 45 C.F.R. Part
1180.44, the undersigned, on behalf of the grantee, certifies that the grantee 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 provides
that no person in the United States shall, on the grounds of race, color, or national origin, be
excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination
under any program or activity receiving Federal financial assistance;
(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 in Federally - assisted programs; (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 activities receiving Federal financial
assistance;
(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 in Federally- assisted programs;
The undersigned further provides assurance that it will include the language of these certifications in all
subawards and that all subrecipients shall certify and disclose accordingly.
As the duly authorized representative of the grantee, I hereby certify that the grantee will comply with the
above certific4ons.
Signature of Aut�rized Certifying Official
Print Name and Title of Authorize8 Certifying Official
9114' I) -
MM
a
Certification Regarding Debarment and Suspension; Lobbying; etc. page 2 of 2
;T o TY
NEW HANOVER COUN
PUBLIC LIBRARY
201 HE
-AROLENA 2��401-30�42
WILWNGTGN. NORTH C 4
Conflict of Interest Poliev
New Hanover Count), Public Library adheres to New Hanover County's policy regarding conflict
of interest as stated in the personnel policy -section 6.3 to 6.7
6.3 Gifts and Favors
No employee of the County, will accept any valuable gift., whether in the fibrin of ser\ ]cc, loan,
thin- or promise from any person who to the employee's knowledge is interested directly or
indirectly in any manner whatsoever in business dealings with the County. No official or
crnployccwvill accept any gift, favor, or thing of value, that may tend to influence that employee
in the discharge of duties. No official or cinployce will grant in the discharge of duties ally
improper favor, service, or thing of value.
6.4 Solicitation Purpose and Applicability
The County fully supports the efforts of employees to raise funds for charitable causes and non-
profit organizations, as long as these activities do not conflict with conducting County business
during regular hours of operation. Therefore, a policy has been developed with respect to
soliciting donations on County property or time. ]-his policy applies to all employees.
6.4.1 Solicitation Police
Employees shall not use the County e-i-nail system to broadcast solicitations for donations to a
charitable cause or non-profit organization, unless with prior approval by the County Manager.
However, employees may use the County intranet site to do so. Soliciting donations for
charitable causes or non-profit organizations Nvithin an employee's department is allowable with
prior approval of the department ]read. Soliciting donations from employees in other
departments must be approved by the County Manager or his designee. Soliciting, taking and
delivering orders, receiving payments and related activities shall not interfere with the
employee's work or the work of others. These activities should be restricted to employee
breaks and lunch times. There may be some fund-raising campaigns endorsed by the County
which may be exempt from the prohibitions ill this policy,
6.5 Political Activity Restricted
Every employee has a civic responsibility to support good government by every available means
and in every appropriate manner. Employees may Join or affiliate with civic organizations of a
partisan or political nature, may attend political meetings, may advocate and support the
principles or policies of civic or political organizations in accordance with the Constitution and
laws of the State of North Carolina and in accordance with the Constitution and laws of the
United States of Arilen'ca. However, no employee will: a. Engage in any political or partisan
activity while on duty (In addition to normal work, the words "on duty" shall be understood
to include attendance and participation in functions where political candidates or parties are
endorsed if County funds are used for expense of traveling or membership in such organization.)-.
b. Use official authority or influence for the purpose of interfering with or affecting the result of
an election or a nomination for office-, c. Be required as a duty of office of employment or as a
condition for employment, promotion. or tenure of office to contribute funds for political or
partisan purposes; d. Coerce or compel contributions for political or partisan purposes by any
other employee of the County-, or e. Use any supplies or equipment or "funds" of the Count} for
political or partisan purposes. County employees in certain federally-aided programs may be
covered by the Hatch Act as amended in 1975. This Federal Act, in addition to prohibiting (b),
(c), and (d) above. also prohibits candidacy for elective office in a partisan election. Any
violation of this section shall be deemed improper and shall subject such employee to dismissal
or other disciplinary action by the appointing authority.
6.6 Outside Employment Purpose and Applicability
i
The County recognizes that sometimes an employee may be employed outside of the County.
However, the ivork of the County Nk Ifl take precedence over other occupational interests or
emplo),inent and this policy provides guidelines for appropriate outside employment, This policy
applies to all County employees.
6.6.1 Outside Employment Policy
Employees may work in outside emploviTient, if the employment is properly requested and
approved and it does not conflict with the employee's County Job. Outside employment is self-
employment or any employment for salaries, wages. tips or commission other than the position
held with the County.
6.6.2 Outside Employment Procedures
Any employee considering outside employment shall report to the responsible supervisor his/her
intentions prior to the beginning of the job, occupation or self-employment, The responsible
supervisor shall review the outside employment and assure that it does not:
a. Coincide or conflict with hours of scheduled work with the
County;
b. Conflict with job responsibilities Or affect the employee's ability
to perfon-n satisfactorily at in the County Job-,
c. Cause an employee to arrive late for, or leave early from, any
scheduled shift or work hours in the County job; or
d. Constitute a conflict of interest with the County.
The supervisor Nvill then forward the request through appropriate routes to the Human Resources
Director (or elected official), who will review the request for potential conflicts of interest or
liabilities with the County in general and give final approval (or denial). Failure to seek approval
for outside employment as outlined above or to maintain such employment when not approved
shall be cause for disciplinary action up to and including dismissal. If attendance or Work
performance is determined to be compromised by outside employment, approval for outside
employment may be withdrawn.
6.7 Prohibited Board, Commission or Committee Service
Persons employed by New Hanover County may not serve on any board, committee or
commission established by resolution or State statutes in the agency or department for which
they work and receive wages. Prior to accepting such an appointment, the employee must
terminate his/her employment with the respective agency or department.
Established May 1977
Last Revised March 12, 2012
NEW HANOVER COUNTY
PUBLIC LIBRARY
201 C'HL;STNUT STRE: T
WILNIIN TON, NORTH C.- Rt)L1NA 28 -1101 -3942
No Overdue 'Fax Debts' Statement
Certification Statement
We certify that the New Hanover County Public Library does not have any overdue tax debts, as
defined by N.C.G.S. 105 - 243.1, at the federal, State, or local level. We further understand that any
person who makes a false statement in violation of NC.G.S. 143C- 6 -23(c) is punishable as provided
by N.C.G.S.143- 34(b).
If there are any questions, please contact the state agency that provided your grant. If needed, you may
contact the North Carolina Office of State Budget and Management at NCGrants (4)osbm.nc_gov or
919-807-4795.
Certification and Signat-ures (Please sign below in blue ink.)
We confirm that the foregoing certification is true, accurate, and complete to the best of our
knowledge. We also acknowledge and understand that any misuse of State funds will be reported to
the appropriate authorities for further action.
Printed name of library director Printed name of local oo�emment or
institutiona.vauthorizine official
Signature of library director Signature of abg�C off
Date
State Library of North Carolina
Date
I G.S. 105 -243.1 defines: "Overdue tax debt. -Any part of a tax debt that remains unpaid 90 days or more after the notice of final
assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the taxpayer entered into an installment agreement
for the tax debt under G.S. 105 <37 within 90 days after the notice of fmal assessment was mailed and has not failed to make any payments
due under the installment agreement."
For W-9
(kev. August 20137
Department or the Treasury
Internal Revenue Service
C�
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Request for Taxpayer
Identification Number and Certification
105 Squwri on y Us €nCtlRle Aix net UFr"f
Business L _Lut jA
1.1-1 ,-Idea entity rame if oifferer�l from
Check aPPIOP'talL box to, lederat tax ciassifrcatio:
lndjvrai,ai/sofe p,cp6etm D n C CerPoraho-, E, S Corpo,alior, Partneship EJ J Tiusestale
Lnlited liabifliv company Ente, the tax classificalior llG corporaho-L S-S corporation, P--partrership) s-
Address (numFer, sl.r I eel, and apt or suile nD)
City, state, arid ZIP code
kcir\
Lisl account riumber(s)her (optional)
I
� u
Exemptions (see iristrucflcns?
Exempt payee code (it any)
Exemption from FATCA reporting
code (if any)
Requester's name and address (optional)
Enter your TIN in the appropriate box, The TIN provided must match the name given on the "Name" line
to avoid backup withholding. For individuals, this :s your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer ident fication, number (EIN} , If you do not have a number, See Tinfory to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for garde Ines on whose
number to enter.
Under penalties of perjury, I certify that:
Tl 2 number
Employer Soci Sao
identification number
F-_7.- -1
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number 10 be issued to me), and
2. 1 am not subject to backup withholding because (a) I am exempt from backup withhoiding, or i I have not been notified by the Internal Revenue
Service (IRS; that I am subject to backup withholding as a result of a failure to report all interest oi dividends, or (c) the IRS has notified me that j am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA codei entered on this form (it any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report ail interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3,
SignjSigriatture of "I
,
Here U.S. p �__ �'11 I"
U.S person P
Date 01
General lnstrucfioAsNik�`e;
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments The IRS has created a page on IRS.gov for information
about Form W-9, at www irs.gov/w9. Information about any future developments
affecting Form W-9 (such as legislation enacted after we release it) will be posted
on that page
A person who is required to file an information return writs the IRS must obtain your
correct taxpayer identification number (TIN) to report, for example, income paid to
you. payments made to You in settlement of payment card and third party network
transactions, real estate transactions, mortgage interest you paid, acquisition, or
abandonment of secured properly, cancel'atior of debt, or contributions you made
to an IRA
Use Form W-9 only if you are a U.S. person (rocodiog a resident Wlen), to
provide your correct TIN to the person requesting it (the requester) and when
applicable. to:
t. Certify that the TIN you are giving is correct (or you are waiting to, a number
to be issued),
2. Certify that you are not subject To backup withholding, or
3. Claim exemption from backup withholding if you are a U.S exempt payee. If
applicable, you are also certifying that as a LJ.S person, your allocable share of
140ing tax on f gr Partners' share of effectively connectec income, and
4. Certify that FATCA code(s) entered or this form (ff any) indicating that you are
exempt from the FAI CA reporting, is correct.
Note. If you are a U.S, person and a requester gives you a form other than Form
W-9 to request your TIN, you must use the requester's form if it is substantially
similar to this Form W-Fir
Definition of a U.S. person. For federal lax purposes, you are considered a U-S.
person if you are:
• An individual who is a U.S. citizen of U S resident alien,
• A parlmo ship, corporation, company, or association created o, organized in The
United States or under the laws of the United Slates,
• An estate (Other than a foreign estate), of
A domestic trust (as defined in Regulations section 301.7701-7)-
Special rules far partnerships- Partnerships that conduct a trade or business in
the United States are generally required to Pay a withholding tax under section
1446 on any foreign partners' share of effectively connected taxable income from
such business Further, in certain cases where a Form W-9 has not been received,
the rules under section 1446 require a partnership to presume that a partner is a
foreign person, and pay the section 1446 withholding tax. Therefore, if you are a
U.S, person that is a partner in a partnership conducting a trade of business in the
United States, provide Form W-9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership income.
any partnership income from a U S trade or business is not subject to the
Cal No 10231X Form W-9 (Rev 8-2013)