FY24 SRC EBHP Title IIIDEBBP County
Title III-D Health Promotion/Disease Prevention
Evidence Based Health Promotion Agreement For
FY 2023-2024
THIS AGREEMENT (hereinafter .referred to as "Agreement") is made and entered into by and
between New Hanover County, (hereinafter referred to as the "County") and Cape Fear Council
of Governments, Lead Regional Organization for the Area Agency on Aging, a public authority
(hereinafter referred to as "Area Agency").
Witnesseth That:
WHEREAS, the Area Agency and the County agree to the terms and conditions for provision of
aging services in connection with activities financed in part by Older Americans Act grant funds,
provided to the Area Agency from the United States Department of Health and Human Services
through the North Carolina Division of Aging and Adult Services (DAAS) and state appropriations
made available to the Area Agency through the North Carolina Division of Aging and Adult
Services, as set forth in a) this document, b) Attachments A and B, c) the Title III-D Evidence
Based Health Promotion Standards found at httus://www.nedhhs.-ov/media/1299/oi,en, and d) the
Division of Aging and Adult Services Community Service Providers Monitoring Guidelines.
NOW THEREFORE, in consideration of these premises, and mutual covenants and agreements
hereinafter contained, the parties hereto agree as follows:
1. The Area Agency agrees to grant Title III-D Evidence Based Health Promotion/Disease
Prevention funds per the NC Division of Aging and Adult Services intrastate funding
formula to the County for the purpose of providing Evidence Based Health Promotion
activities for senior adults described herein and in accordance with the NC Division of
Aging and Adult Services Title III-D Aging Service Standards as well as Title 11I-D Health
Promotion and Disease Prevention Revision: Administrative Letter No. DAAS-12-05,
dated April 24, 2012. The terms set forth in this agreement for payment are contingent
upon availability of funding.
2. Grant Amount. The total payment under this contract shall not exceed $15,533.00 for
disease prevention and health promotion. The County is accountable for ensuring the local
cash matching requirement for $1,725.00 is provided.
3. Grant Administration. The grant administrator for the Area Agency shall be: Holly Pilson,
Area Agency on Aging Director, Cape Fear Council of Governments.
The grant administrator for the County shall be: Amber Smith, NHC Senior Resource
Center Director.
It is understood and agreed that the grant administrator for the County 'Shall represent the
County in the performance of this Agreement. The County shall notify the Area Agency
in writing if the administrator changes during the grant period.
EBHP County
4. Services authorized through the County, as specified on the EBHP 2024 Scope of 'Work
and Budget Spreadsheet in Attachment A, are to commence no later than July 1, 2023 and
shall be undertaken and pursued in such sequence as to assure their expeditious completion
and pursuit to all required standards and guidelines. All services required hereunder shall
be completed on or before the end of the Agreement period, June 30, 2024.
5. Assi2nabili«v and Contractinp . The County shall not assign all or any portion of its interest
in this Agreement. Any purchase of -services with Evidence Based Health Promotion for
Older Adults funding shall be carried out in accordance with the procurement and
contracting policy of the community services provider or, where applicable, the Area
Agency, which does not conflict with procurement and contracting requirements contained
in 45 CFR Part 75, Subpart D-Post Federal Award Requirements, Procurement Standards.
Federal funds shall not be awarded to any subrecipients who have been suspended or
debarred by the Federal government. In addition, Federal funds may not be used to
purchase goods or services costing over $100,000 from a vendor that has been suspended
or debarred from Federal grant programs.
6._ Documentation of Expenses. The County shall maintain full and complete documentation
of all expenses associated with performing Title III-D activities. Documentation in the
form of paid invoices and canceled checks shall be submitted to the Area Agency at the
time of the reimbursement request. County shall maintain all financial and program
records for a period of three (3) years from the date of final payment under this agreement.
7. Compensation and Pm-ments to the County. The County shall be compensated for the work
and services actually performed under this Agreement by payments to be made monthly
by the Area Agency. Total reimbursement to the community service providers under this
Agreement may not exceed $15,533, as specified on the EBHP 2024 Scope of Work and
Budget Spreadsheet in Attachment A.
a. Reimbursement of Service Costs: Payment will be based upon the Aging Resource
Management System (ARMS) Provider Reimbursement Report (ZGA370-7). The
Cape Fear Council of Governments will forward payment of the approved budget
expenditure at the end of each month. The County must submit quarterly reports to the
Cape Fear Council of Governments.
b. AE inc Resource Management System iARMSj Requirements: All program
performance and financial reports must conform to the requirements of the Division of
Aging and Adult Services' automated Aging Resource Management System (ARMS),
The County will be required to participate in the automated ARMS by supplying the
necessary and required input data. The County will also be required to participate in
appropriate workshops by the Division of Aging and Adult Services and/or Area
Agency on Aging. Failure to comply with the reporting requirements may results in
either withholding of funds or possible suspension/termination of funding. The County
is required to participate in the ARMS user's fee. The fee shall apply to each of the
categories as the reimbursements are requested through ARMS. It shall be based on the
following formula:
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EBHP County
# of records X $.17 maintenance cost per service record in ARMS
c. Documentation of Ex enses: The County shall maintain full and complete
documentation of all expenses associated with performing the scope of work under this
contract. Documentation in the form of time sheets or other verification (prior approval
required) that services were rendered shall be kept in each client file. The County shall
maintain all financial and program records for a period of seven (7) years form the date
of final payment under this agreement.
8. Reallocation of Grant Funds. It is understood and agreed, that in the event that the County's
rate of progress on this contract is leading to underutilization of the funds allocated, and if
the County cannot demonstrate how funds will be fully utilized during the contract period,
then, upon notice to the County, the Council may decrease the total compensation to be
paid hereunder in order to reallocate funds to other Grantees.
9. Amendments and Reeroarammin[ of Funds. This contract may be modified by written
amendment at any time. It is understood and agreed that, in the event that the amount of
funds received from the NC Division of Aging and Adult Services is reduced or increased
from the amount(s) quoted, the Area Agency may, in turn, decrease or increase the total
compensation and reimbursement to be paid. Such changes, including any increase or
decrease in the amount of the County's compensation shall be incorporated in written
amendments to this contract and signed by both parties.
10. Monitorini,- Auditing and Reporting. The County agrees to have an annual independent
audit in accordance with North Carolina General Statutes, North Carolina Local
Government Commission requirements, Division of Aging and Adult Services Program
Audit Guide for Aging Services and 2 CFR Part 200.
The County is subject to audit and fiscal reporting requirements, as stated in 2 CFR Part
200, where applicable. The County must send a copy of their year-end financial statements,
and audit, to the Area Agency. EBHP providers are not required to submit Activities and
Accomplishments Reports. Federal funds may not be used to pay for a Single or Yellow
Book audit unless it is a federal requirement. State funds will not be used to pay for a
Single or Yellow Book audit if the provider receives less than $500,000 in state funds. The
Department of Health and Human Services will provide confirmation of federal and state
expenditures at the close of the state fiscal year. Information on audit and fiscal reporting
requirements can be found at
leis://www.nci�rants. ov/NCGrants/PubiicRe •ortsRei?ulations.isq�
Consumer Contributions. The County must allow for "consumer contributions" (client
must be given opportunity to contribute to defray the cost of the service but may not be
denied service should he/she fail to or choose not to contribute). The NC Division of
Aging and Adult Services Home and Community Care BIock Grant Service Standards for
Consumer Contributions will be followed, and a signed/dated provider assurance form
must be present in each client file. Please review the Consumer Contributions Policy and
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EBHP County
Procedures at: bttp:// wvw.ncdhhs.mov/documennt/oonsumer-contributions-policy-and-
procedures
The following provides a summary of reporting requirements under NCGS 143C-6-22 and
23 and 2 CFR Part 200 based upon funding received and expended during the service
provider's fiscal year.
AnnualR,eport.11 cquirod to AAA
Ex seridi tares
Less than $25,000 i Certification form and State Grants
in State or Federal Compliance Reporting <$25,000 (item #
funds 11, Activities and Accomplishments does
not have to be completed)
OR
Audited Financial Statements in
Compliance with GAO/GAS (i.e. Yellow
Greater than
$25,000 and less
than $500,000 in
State funds or
$750,000 in
Federal funds
$500,000 or more
in State funds but
less than $750,000
in Federal pass
through funds
$500,000 or more
in State funds and
$750,000 or more
in Federal pass
throunh funds
Allowable Cost
for RepDr-ting
N/A
Certification form and Schedule of County N/A 1
Receipts >$25,000 and Schedule of
Receipts and Expenditures
OR
Audited Financial Statements in
Compliance with GAO/GAS (i.e.
Book)
Audited Financial Statements in
Compliance with GAO/GAS (i.e.
Book)
Yellow
May use State
Yellow funds, but not
Federal Funds
Audited Financial Statement in compliance May use State and
with OMB Uniform Guidance 2 CFR Part Federal funds
200 (i.e. Single Audit)
Less than Audited Financial Statement in compliance May use Federal
$500,000 in State with OMB Uniform Guidance 2 CFR Part funds, but not State
funds and 200 (i.e. Single Audit) funds.
$750,600 or more
in Federal pass
throuiih funds
Representatives of the Area Agency and the NC Division of Aging and Adult Services may
at any reasonable times review and inspect the service activities and data collected pursuant
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EBHP County
to this Agreement. All reports and computations prepared by or for the County shall be
made available to authorized representatives of the Area Agency, and the NC Division of
Aging and Adult Services for inspection and review at any reasonable time in the County's
office. Approval and acceptance of such material shall not relieve the County of its
professional obligation to discover and correct, at its expense, any errors found in the work.
It is further understood that the County is responsible to the Area Agency for clarifying
any audit exceptions that may arise from any Area Agency assessment, County or
community service provider single or financial audit, or audits conducted by the State or
Federal Governments. In the event that the Area Agency or the Department of Health and
Human Services disallows any expenditure made by the community service provider for
any reason, the County shall promptly repay such funds to the Area Agency once any final
appeal is exhausted in accordance with paragraph eleven (11).
To ensure adequate review and evaluation of the work and proper coordination among
interested parties, the Area Agency shall be kept fully informed concerning the progress of
the work and services to be performed. County agrees to submit to the Area Agency, each
quarter, a list of those EBHP required programs that have been provided and what outreach
activities (for example: media efforts) have been expended in order to increase capacity to
serve the County with EBHP. Area Agency staff will conduct on -site assessments and may
also make unannounced visits for the purpose of evaluating the County's work.
11. Disputes and Appeals. Any dispute concerning a question of fact arising under this
Agreement shall be identified to the designated grants administrator for the Area Agency.
In accordance with Lead Regional Organization (LRO) policy, a written decision shall be
promptly furnished to the designated grants administrator for the County.
The decision of the LRO is final unless within twenty (20) days of receipt of such decision
the Chairman of the Board of Commissioners furnishes a written request for appeal to the
Director of the North Carolina Division of Aging and Adult Services, with a copy sent to
the Area Agency. The request for appeal shall state the exact nature of the complaint. The
Division of Aging and Adult Services will inform the Chairman of the Board of
Commissioners of its appeal procedures and will inform the Area Agency that an appeal
has been filed. Procedures thereafter will be determined by the appeals process of the
Division of Aging and Adult Services. The state agency address is as follows:
Director
North Carolina Division of Aging and Adult Services
693 Palmer Drive
2101 Mail Service Center
Raleigh, North Carolina 27699-2101
12. Termination for Cause. If through any cause, the County shall fail to fulfill in a timely and
proper manner its obligations under this Agreement, or the County has or shall violate any
of the covenants, agreements, representations or stipulations of this Agreement, the Area
Agency shall have the right to terminate this Agreement by giving the Chairman of the
EBHP County
Board of Commissioners written notice of such termination no fewer than fifteen (I5) days
prior to the effective date of termination. In such event, all finished documents and other
materials collected or produced under this Agreement shall at the option of the Area
Agency, become its property. The County shall be entitled to receive just and equitable
compensation for any work satisfactorily performed under this Agreement
13. Indemniil: . The County agrees to indemnify and save harmless the Area Agency, its agents,
and employees from and against any and all loss, cost, damages, expenses, and liability
arising out of performance under this Agreement.
14. Attendance at Re}jon O Area Agency on Aging Meeting The County, upon request of
the Area Agency grant administrator, will make efforts to attend any committee or special
meeting relating to the project. The County will attend any scheduled Evidence Based
Health Promotion (EBHP) meetings.
15. Equal Employment Opportunity and Americans With Disabilities Act Comr-liance. The
County shall comply with all federal and state laws relating to equal employment
opportunity and accommodation for disability.
16. Data to be 1"umished to the Countv. All information which is existing, readily available to
the Area Agency without cost and reasonably necessary, as determined by the Area
,Agency's staff, for the performance of this Agreement by the County shall be furnished to
the County and community service providers without charge by the Area Agency. The
Area Agency, its agents and employees, shall fully cooperate with the County in the
performance of the County's duties under this Agreement.
17. RWhts in Documents_ Materials and Data Produced. The County agrees that at the
discretion of the Area Agency, all reports and other data prepared by or for it under the
terms of this Agreement shall be delivered to, become and remain, the property of the Area
Agency upon termination or completion of the work. Both the Area Agency and the
County shall have the right to use same without restriction or limitation and without
compensation to the other. For the purposes of this Agreement, "data" includes writings,
sound recordings, or other graphic representations, and works of similar nature. No reports
or other documents produced in whole or in part under this Agreement shall be the subject
of an application for copyright by or on behalf of the County.
18. Interest .of the Board of Commissioners. The Board of Commissioners covenants that
neither the Board of Commissioners nor its agents or employees presently has an interest,
nor shall acquire an interest, direct or indirect, which conflicts in any manner or degree
with the performance of its service hereunder, or which would prevent, or tend to prevent,
the satisfactory performance of the service hereunder in an impartial and unbiased manner.
19. Interest of Members of the Area AF2ency, Lead Regional Organization, and Others. No
officer, member or employee of the Area Agency or Lead Regional Organization, and no
public official of any local government which is affected in any way by the Project, who
exercises any function or responsibilities in the review or approval of the Project or any
6
BBHP County
component part thereof, shall participate in any decisions relating to this Agreement which
affects his personal interest or the interest of any corporation, partnership or association in
which he is, directly or indirectly, interested; nor shall any such persons have any interest,
direct or indirect, in this Agreement or the proceeds arising there from.
20.Officials not to Benefit. No member of or delegate to the Congress or Resident
Commissioner, or employee of the United States Government, shall be entitled to any share
or part of this Agreement or any benefits to arise therefrom.
21. Prohibition AR-ainst Use of Funds to Influence Legislation. No part of any funds under this
Agreement shall be used to pay the salary or expenses of any employee or agent acting on
behalf of the County to engage in any activity designed to ' influence legislation or
appropriations pending before Congress.
22. Conflict of interest. The County shall comply with all applicable federal and state conflict
of interest laws. The County expressly states that presently they have no interest and shall
not acquire any interest, direct or indirect, which would conflict in any manner or degree
with the performance of services required to be performed under this contract. The County
shall employ any person having such interest during the performance of this contract. The
County further,agrees to notify the Area Agency on Aging in writing of any instance that
might have the appearance of a conflict of interest.
23. ConfidentialiL% and Securit-:. Any client information received in connection with the
performance of any function of a community service provider or its subcontractors under
this Agreement shall be kept confidential, The community service provider acknowledges
that in receiving, storing, processing, or otherwise handling any confidential information,
the agency and any subcontractors will safeguard and not further disclose the information
except as provided in this Agreement and accompanying documents.
24. Record Retention and Disposition. All state and local government agencies,
nongovernmental entities, and their subrecipients, including applicable vendors, that
administer programs funded by federal sources passed through the NC DHHS and its
divisions and offices are expected to maintain compliance with the NC DHHS record
retention and disposition schedule (https://www.nedhhs.-ov/about/administratiye-
ofFices/off ce-controller/records-retention). In addition, the NC Department of Natural and
Cultural Resources has developed a General Records Schedule for Local Government
Agencies as well as individual retention and disposition schedules for local government
agencies like County social service agencies and local health departments. Those schedules
are posted at httr.s:/Iarchiyes.ncdcr.goy/govemment/local
Retention requirements apply to the community service providers funded under this
Agreement to provide Evidence Based Health Promotion services. By funding source and
state fiscal year, the NC DHHS record retention schedule lists the earliest date that grant
records in any format may be destroyed. The State Archives provides information about
destroying confidential data and authorized methods of record destruction (paper and
electronic) at http0larchives.nedcr. ov/;government/records-mana,7ement-tools/fa�4.I_ow-
7
EBBP County
can-i-destroy-records.
25. Additional provisions.
a. County and any subrecipients are required to follow policies and procedures for
procurement that are at least as stringent as those of the State. For federal funds this
requirement pertains to verifying that federal funds are not used to award funds to any
subrecipients who have been suspended or debarred by the federal government. In
addition, federal funds may not be used to purchase goods or services costing over
$100,000 for a vendor that has been suspended or disbarred from Federal grant
programs. Contractors and subcontractors of Older Americans Act funds are prohibited
from discharging, demoting, or otherwise discriminating against and employee for
whistle blowing as codified in 48 CFR Ch. 13.909.
b. Any capital purchases of $5,000 or more must be pre -approved by the Area Agency
and the Division of Aging and Adult Services.
c. If any copyrightable material is developed in the course of or under this agreement and
any subaward, a copy will be furnished to the Department of Health and Human
Services and the Department shall have a royalty fee, non-exclusive, and irrevocable
right to reproduce, publish or otherwise use the work for Department purposes.
d. In accepting this award, the County agrees not to replace local program support with
Total Federal/State Reimbursement and will contract for any aging services as
identified through the County funding plan in accordance with policies and procedures
established in the Division of Aging and Adult Services Manual of Policies and
Procedures. httys:Hpolicies.ncdhhs.yov/divisionaUaiiini_-and-adult
e. County and any subrecipients shall comply with the Federal Funding Accountability
and Transparency Act (FFATA) by enrolling as a subrecipient in System for Award
Management (SAM) Registration on an annual basis'and providing required award
information in the FFATA Subaward Reporting System per 2 CFR part 170.
f. In accepting this award, County and any subrecipients agree to maintain compliance
with Section 306(a), (13), (14), and (15), of the Older Americans Act, as amended in
2006 with regards to contractual and commercial relationships.
g. By signatures on Attachment B, Federal Certifications, the County certifies its
compliance and compliance of any subrecipients with federal requirements regarding
nondiscrimination; drug -free workplace; environmental tobacco smoke; debarment,
suspension, ineligibility, and voluntary exclusion lower tier covered transactions; and
lobbying.
h. E-Verify Comp}fiance. Pursuant to Session Law 2013-418, Contractor shall fully
comply with the U.S. Department of Homeland Security employee legal status E-
Verify requirements for itself and all its subcontractors, if applicable. requires an
E&HP County
affidavit attesting to Contractor's compliance. Violation of the provision, unless timely
cured, shall constitute a breach of contract.
26. Federal Award Identification. This Agreement constitutes a subaward of federal funds,
the details of which are provided below pursuant to 2 CFR 200.332(a)(1):
Subreci. ient name:
New Hanover County
Subreci ient's unique entity identifier:
F7TLT2GMEJEI
Federal Award Identification Number (FAIN);
AANCT3PH
Federal Award Date:
07-01-2023
Subaward and Budget Period of Performance
End Date:
07/01/2023 — 6/30/2024
Amount of Federal Funds Obligated to the
Subreci -lent by this action:
$15,533
Total Amount of Federal Funds Obligated to
the subrecipient by CFCOG:
$1,309,730
Total Amount of the Federal Award Committed
to the subrecipient by CFCOG:
Title III-D Evidence Based Health
Promotion
Federal award project description :
Title III -B Su _ortive Services
Federal awarding agency:
i Administration on Community Living
Federal recipient:
North Carolina Department of Health and
Human Services Division of Aging and
Adult Services
Subawarding agency:
Cape Fear Council of Governments
Subawarding agency contact information:
Holly Pilson, Area Agency on Aging
Director (910) 274-0339
Assistance listings number and title:
93.043 Title III-D Evidenced Based Health
Promotion
No
Research and development:
27, Applicable Law. This Agreement is executed and is to be performed in the State of
North Carolina, and all questions of interpretation and construction shall be construed by
the laws of such State.
EBBP County
In witness whereof, the Area Agency and the County have executed this Agreement as of the day
first written above.
THE COUNTY OF NEW HANOVER:
Agency•on Aging Director
Executive Director
This instrument has been preaudited in the manner required by the Local Government Budget and
Fiscal Control Act.
By. _
awii ticker, Finance Director
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ATTACHMENT B — FEDERAL CERTMCAT)IONS
The undersigned states that:
1. He or she is the duly authorized representative of the Provider named below;
2. He or she is authorized to make, and does hereby make, the following certifications on
behalf of the Provider, as set out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug -Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion Lower Tier Covered Transactions; and
e. The Certification Regarding Lobbying;
3. He or she has completed the Certification Regarding Drug -Free Workplace Requirements
by providing the addresses at which the contract work will be performed;
4. [Check the applicable stktement]
[ ] He or she has completed the attached Disclosure of Lobbying Activities because the Provider
has made, or has an agreement to make, a payment to a lobbying entity 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 a covered
Federal action;
OR
M He or she has not completed the attached Disclosure Of Lobbying Activities because the
Provider has not made, and has no agreement to make, any payment to any lobbying entity for
influencing or attempting to influence any officer or employee of any agency, any Member of
Congress, any officer or employee of Congress, or any employee of a Member of Congress in
connection with a covered Federal action.
S. The Provider shall require its subcontractors, if any, to make the same certifications and
disclosure.
Assistant County Manager
e Title
New anover County Senior Resource Center /QI /5 Z,9Z3
Provider 1. w+,te I — -
I. Certification Regarding Nondiscrimination
The Provider certifies that it will comply with all Federal statutes relating to nondiscrimination.
These include but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color or national origin; (b) Title IX of the
Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and 1685-1686), which
prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age
Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6I07), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L.
92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and AIcoholism Prevention, Treatment and Rehabilitation Act of
1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or
alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food
Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political
beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this
Agreement.
H. Certification Regarding Drug -Free Workplace Requirement
1. The Providgr 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 is prohibited in the Provider'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;
H. The Provider'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 be engaged in the performance of the
agreement 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 agreement, 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 Department within ten days after receiving notice under subparagraph (d)(ii)
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)(ii), 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 Federal, State, or local health,
law enforcement, or other appropriate agency; and
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).
2. The sites for the performance of work done in connection with the specific agreement are
listed below (list all sites; add additional pages if necessary):
Street Address, City, State: Zip Code I
2222 S Collei�e Rd. Wilmington, NC 28403
3. Provider will inforin the Department of any additional sites for performance of work under
this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment,
suspension or termination of grants, or government -wide Federal suspension or debarment.
45 C.F.R. 82.510.
111. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro -Children Act
of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned
or leased or contracted for by an entity and used routinely or regularly for the provision of health,
day care, education, or library services to children under the age of 18, if the services are funded
by Federal programs either directly or through State or local governments, by Federal grant,
contract, loan, or loan guarantee. The law does not apply to children's services provided in
private residences, facilities funded solely by Medicare or Medicaid funds, and portions of
facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of
the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day
and/or the imposition of an administrative compliance order on the responsible entity.
The Provider certifies that it will comply with the requirements of the Act. The Provider further
agrees that it will require the language of this certification be included in any subawards that
contain provisions for children's services and that all
subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion
Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Provider.]
1. By signing and submitting this document, the prospective lower tier participant is providing
the certification set out below.
2. The certification in this clause is a material representation of the fact upon which reliance
was placed when this transaction was entered into. If it is Iater determined that the
prospective lower tier participant knowingly rendered an erroneous certification, in addition
to other remedies available to the Federal Government, the department or agency with which
this transaction originate may pursue available remedies, including suspension and/or
debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to
whom this proposal is submitted if at any time the prospective lower tier participant learns
that its certification was erroneous when submitted or has become erroneous by reason of
changed circumstances.
4. The terns "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered
transaction," "participant," "person," "primary covered transaction," "principal," "proposal,"
and "voluntarily excluded," as used in this clause, have the meanings set out in the
Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR
Part 76. You may contact the person to whom this proposal is submitted for assistance in
obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter any lower tier
covered transaction with a person who is debarred, suspended, determined ineligible or
voluntarily excluded from participation in this covered transaction unless authorized by the
department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will
include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion --Lower Tier Covered Transaction," without modification, in all lower
tier covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended, ineligible, or
voluntarily excluded from covered transaction, unless it knows that the certification is
erroneous. A participant may decide the method and frequency by which it determines the
eligibility of its principals. Each participant may, but is not required to, check the
Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
a. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who
is suspended, debarred, ineligible, or voluntarily excluded from participation in this
4
transaction, in addition to other remedies available to the Federal Government, the
department or agency with which this transaction originated may pursue available remedies,
including suspension, and/or debarment.
Certification
1. The prospective lower tier participant certifies, by submission of this document, that
neither it nor its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or. voluntarily excluded from participation in this transaction by any
Federal department or agency.
2. Where the prospective lower tier participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Provider 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 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 any Federal contract,
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 agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this Federally funded contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure
of Lobbying Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award
document for subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) who receive federal funds of $100,000.00 or more
and that all subrecipients shall certify and disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed when
this transaction 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, U.S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than $10,000.00 and not more than $100,000.00 for each such failure.
VI. Disclosure of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee 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 1st tier. Subawardsinclude but are
not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing 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 (11713)
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.
12. Check the appropriate boxes. 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 boxes. Check all boxes that apply. If other, specify nature.
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 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 of information 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 (0349-0046), Washington, D. C, 20503
FORM CD-511 U.S. DEPARTMENT OF COMMERCE
(REV 05117) CERTIFICATION REGARDING LOBBYING
Applicants should also review the instructions for certification Included In the regulations before completing this form. Signature on this form provides for
compliance with certification requirements under 15 CFR Part 28, 'New Restrictions on Lobbying' The certifications shall be treated as a material representation
of fact upon which reliance will be placed when the Department of Commerce determines to award the covered transaction, grant, or cooperative agreement.
LOBBYING
As required by Section 1352, Title 31 of the U.S. Code, and Implemented
at 15 CFR Part 28, for persons entering into a grant, cooperative
agreement or contract over $100,000 or a loan or loan guarantee over
$150,000 as defined at 15 CFR Part 28, Sections 28.105 and 28.110, the
applicant certifies that 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
behaif of the undersigned, to any person for Influencing or attempting to
influence an officer or employee of any agency, 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.
(2) If any funds other than Federal appropriated funds have been paid or will
be paid to any person for influenging or attempting to influence an officar 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.
I
(3) 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 subreeipients shall certify and
disclose accordingly.
This certification is a material representation of fact upon which reliance
was placed when this transaction 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, U.S. Code. Any person who
fa€Is 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
occurring on or before October 23, 1996, and of not less than $11,000 and
not more than $110,000 for each such failure occurring after October 23,
1996.
Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief,
that:
In any funds have been paid or will be paid 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 this commitment providing for the
United States to Insure or guarantee a loan, the undersigned shall
complete and submit Standard Form-LLL, 'Disclosure Form to Report
Lobbying; In accordance with its instructions.
Submission of this statement Is a prerequisite for making or entering into
this transaction imposed by section 1352, title 31, U.S. Code. Any person
who fails to file the required statement shalt be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure
occurring on or before October 23, 1996, and of not less than $11,000 and
not more than $110,000 for each such failure occurring after October 23,
1996.
As the duty authorized representative of the applicant, I hereby certify that the appllcant will comply with the above applicable certification.
NAME OF APPLICANT
New'Hanover:',. outs
* AWARD NUMBER * PROJECT NAME
t32H '#itle 110. 2n,'%4
Prefix: ' First Name: Middle Name:
Tufaiirl
* Last Name:
Title: ASS
" SIGNATURE:
]Completed by Grant.01%)" submission. IV
Suffix:
* DATE: /4P/I3 Z�j
lCompleted'by Grahts•gov upon submission.
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
See reverse for-.ublic burden disclosure.)
1. Type of Federal Action:
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance
2. Status of Federal Action:
a. bidlofferlapplication
b. initial award
c. post -award
4. Name and Address of Reporting Entity:
Q Prime Q Subawardee
Tier if known:
Congressional District, if known:
6. Federal DepartmentlAgency:
8. Federal Action Number, Ifknown:
3. Report Type:
El a. initial filing
b. material change
For Material Change Only:
year quarter
date of last report _.
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Congressional District, if known:
7. Federal Program NameiDescription:
CFDA Number, if applicable:
9. Award Amount, if known:
10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
f if.lndividuai.-.last.name. firsf.nama..Mll:._ _- ... different from No. 10a)
_ 1astname. fVst_name. MI_):_.
11. tnfermation requested through this form is authorized by title 31 U.S-C. section
Signature:
1352. This disdcsure of lobbying act[villas is a material representation of fact
— —
upon which rallahce was placed byths tier above when He transeellon wee made
Print Name: '
or entered Into. This disclosure Is required pursuant to 31 U.S.C, 1352, This
—
Information Q1 be reported to the Congress semi-annually and Mil be avallab€e for
Title:
public inspection. Any person who falls to file the required disclosure shall be
subject to a cMI penalty of not less that $10,000 and not more then $100,ann for
each suchfaiture.
Telephone No.:
Federal Use Only:
Date:
Authorized for Locai Reproduction
Standard Form LLL (Rev. 7-9r
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee 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 agreementto make
paymentto any lobbying entilyfor influencing or attempting to Influence an officer or employeeof any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Memberof Congress in connection with a covered Federa€ action. Completeall items that applyfor 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 influents the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropdateciass€flcatlon of this report. If this Is a followup 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 1 st tier. Subawards include but aro not iimiled to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in Item 4 checks "Subawardea," then enter the full name, address, city. State and zip code of the prime Federal
recip€ant. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevet 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 foan commitments.
8. Enter the most appropriate Federal Identifying number avallablefor 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 awardhoan
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 registrant under the Lobbying Disclosure Act of 1995 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. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid CM Control
Number. The valid OMB control number for this information collection is OMB No. 0346-0046. Public reporting burden for this collection of information is
estimated to average 10 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 Managementand Budget. Paperwork Reduction Project (0348-0046), Washington,
DC 20503.