MCSO OJP.PDF

U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
OFFICE OF THE COMPTROLLER
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they are required to
attest. Applicants should also review the instructions for certification included in the regulations before completing this
from. Signature of this form provides for compliance with certification requirements under 28 CFR Part 69, "New
Restrictions on Lobbying" and 28 CFR Part 67, "Government-wide Department and Suspension (Nonprocurement) and
Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material
representation of fact upon reliance will be placed when the Department of Justice determines to award the
covered transaction, grant, or cooperative agreement.
1. LOBBYING lic (Federal,. State,. gr local) tra action or c tract under a
aesiraonsagrointhisva lgtionf otem zdergrineloir+ lorWretit,st
As required by 213e8t6y 1 ,1Ai,9Tple r persions 31 of the entering .U..S. into_a aiirg orir erv, falsification . or cleslruction .oztz records, making YalsYd
or aPRo6D6) en6lalivaej, grgretm csRtifirsetrh1P0,uuu, as detinal a 2b sta ements, or receiving stolen property,
(c) Are not presently indicted for or otherwise criminally orilly
(a) No Federal appropriate funds have been paid or will be paid, charg ed by a ,goverhin.ental.entity (Federal, State, or lbcal Nltn
by or on behalf of the undersigned, to any person for influencing QOM Isslan ocany or the. offenses enumera ed in paragraph (1)
or attempting to influence an officer or employee of any agency, (b) o this certiticatIon ; and
a Member cif Congress, an officer or employee of Congress, or
an employee of a Member of Concress in connection with the
making of any Federal grant he entering into of any icl) ad Have one not or within more a public three-y ansaCtions ear period SVPg gleapgi5Ot S13
cooperative agreement, and extension, continuation, renewal, terminated for cause or de ault; and
amendment, or modification of any Federal grant or cooperative
agreement;
B. Where the applicant is. unable to certify to any gf the
statements in this certification, ne or she shall attach an
explanation to this application.
OrnIvitfjggs etrotrI rliFofjseoR f.grrrifgiraiL7r%fuadaii%v
Member
61\ 1-11Pecfs aanri ficceerr eem Reeeeo?C85treqpino aS ern, o lov _ e 8
a mbei- o oncress in. co neftion is ii e era grant or R9ACt2EFSR8TINT(FrALNAWDI VI DUALS)
cogvre.rtatiqaragralaTnn4no. ersinned
TisclOsiare coorPpLajgbylRga
rcrivitlies,w in accordance with its inetructions; As renuired b the u -Fre Wnrknlace t of 1988, and
Icri5 Ir7er5eLite43 a M Pfk tPtic7tioDYR.g1ihrd Vr.g5Vr as
I he undersigned shall require that the language lot this cer-
lit cation be inoltided in t e award documents ICT alrsubawards at 'Irug-Ift1SeaNci'vE,INradiatcseigies that it will or will continue to provide a
a tiers. (i ncluding su grants contracts under grants an d
cooperativ aqree ents and Subcontracts and trrat all sub-
recipients shalrcertiry and disclose accordingly.
(a) I-'bJishing f a t statemen t notifying enfloyees that the
-trip4 ,inpvsess. iaongeeor
ffsfeavgP ia meolinSeuciesubstance the
WRIghtrYgigION, ANL) 01 Vitt< workplace and specifying e actions %ar will be against
employees tor violation oT such proh ibition;
11:2) Establishing an on-going drug-free awareness program to
As required by Executive Order 12549, Debarment and inform employees about-
Suspension, E .anC implemented at 2f3 CI-K Hit 6/ for prospective
cloanprimary covered transactions, aS cietineC at 2b
Hart 7, ection 57.510- (1) The dangers of drugs abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
A. The applicant certifies that it and its principals:
131 Any available drug counseling, rehabilitation, and employee
(a) Are not presently debarred, suspended, proposed for debar- assistance programs; an
ment declared ineligible, sentenced to a denial of Federal
benefits by a State or-Federal court, or voluntarily excluded from (4) The penalties that may. be, imposed upon employees for drug
covered transactions by any Federal department or agency; abuse violations occurring in me workplace;
(c) Making it a requirement that each employee to be engaged in
b) Have not within a three-year period receding this application the pertonance Pt the grant be given a copy of the statement
been convicted of or had a t rendered against tne ri required by paragraph (a7;
or commission of fraud or a crimirta o ense in contTection win
obtaining, attempting to obtain, or perorming a Notifying the employee, in ..the statement required by
aragrapti a) tnat, as a condition of employment under tne grant,
e employee wiii-
OJP FORM 4061/6 (3-91) REPLACES OJP FORMS 4061/2, 4062/3 AND 4061/4 WHICH ARE OBSOLETE.

(1) Abide by the terms of the statement; and
DEA Arizona Offices
(2 Notify t he employer in wrilinci of his .or her conviction for a
vio lation (D. a criminal drug statute occurring in the worKplace no
later than fi ve calendar days a er such coraiction;
(e) Notif inq the agency, in writinc, with0 1 calendar days after
receivin motice anger subrraoraph. )( trom an employee Check if there are workplace on file that are not identified
ar otherwise rece \nog a tuar notice o . such . convicti .n. nere.
Employers of convicted ema oyees mrt provide notice or inciu qin
osition title • 7artnir or 4s oftixe J
roqrams esk, 6 ni n Section 67, 630 of the r aulations provides.that a grantee that is
otice shall incluadeatheIllunlificatiori a state may elect to, ma e one certiticarn in.each rederal fiscal
num er s of each attected grant; year. A oioy opt rjjcrs ould e mow ea with each application application
tor uepa (-lent o .0 ice km states and state
may elect to use K orm 4U 1/7.
Takina one, of the. followina actions, within 30 calendar
5 sVecciftaigIATIolegi7hougleorcosnuy'?gtaerSgraph (d)(2), with Check r if the State has elected to complete OJP Form
4061/7.
(1) -faking appropriate mrsonnel . action aaainst tsucth tan
employee, up to ,,, i DRUG-FREE WORKPLACE
requirements of the Ken hIli 1 1 ISIPortie IhclIrOriV/.3'nsgntieehnd'eTi;horhe (GRANTEES WHO ARE INDIVIDUALS)
(2) Requirina such employee to participatesatisfactorily in a drua As reauired by the _Drua-Free 7Workplace_Act of 1988, and
pebutp uspeseas_styglaahndoerralel.glieta OcrloEL'IURhatinDveenqoP2rrgP ir?erlealt5g 61i8PM7;PgetcOoris%tf.g?Et ad t8 .82)r-'tees, as
id' WI lel dippropriate agency; " '
A. As a condition of the grant I certify that I will not engage in
(g) Making a good faith effort to continue to maintain a drug- free the or use unlavytui of a controlled manufacture, substance distribution, in condition disp.ensinq ariy activity possesson with
workplace through implementation of paragraphs (a), (b), (c), (d), tne grant; and
(e), and (f).
B. The the site B. If convinced of a criminal drug offense resulting, from a
ugeongg eRrse 80- 1ce e with e violation occurring during the concludt of any grant activity, I will
eci lc gra nt: report the conviction, in writing, within 10 carendar days of the
conviction, to: Department of Justice, Office of Justice Frograms,
Place of Performance (Street address, city, country, state, zip ATTN: Control Desk, 633 Indiana Avenue, NW., Washington,
code) D.C. 20531.
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.
1. Grantee Name and Address:
Maricopa County on behalf of the Maricopa County Sheriff's Office
301 West Jefferson, 10th Floor
Phoenix, AZ 85003
2. Application Number and/or Project Name 3. Grantee IRSNendor Number
4, Typed Name and Title of Authorized Representative
Chairman Board of Supervisors
5 Signature 6. Date