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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
Sof eqeires by seetn Age Bo dps pabone: entering i in neg aaa ae
Bare te sesaar ear he a
Ig (apeaeuione iclaton, of Seer S Sr ° ees antieud
commission, of zzlemen forge
ery falsification or destruction to records, mak ing e
ant is, or receiving stolen property;
I
a) No Fi eral he priate funds have been paid or will @ paid, aie st egoverhenetial Om siminal ally ot cal aipwih,
3) or on @ undersigned, to any person fp r influencin' $10) of an fe offenses enumerated te parag raph
or attempting to influence an fice or employee ny a ney Of this cortices jon, and
a Member S) Congress, en on er or emp! ayee (ej ran gre ana
making 3 egy aan mer of Con ress, connection fe) an t d Have not within 2, ear eriod RES gecing dhis appliqation
cooperative agreement, and extension, continuation, renewal, Wad one. OF more put ete ath ns (Federal,” State, “or local)
amendment, of modification of any Federal grant or cooperative
agreement; .
Saterents ine thie Pogeication, he % eM Bach Bh
any fl {upds ot ot et than Federal Fd sae fund hav been explanation to this app’ ication
be or will rs encing or Big ae
to any person fo
S/Sk Sh St of UN NS® PLBTH SHPO) terete 9
“FREE WORKPLACE
5 see Waa tee nent es ee, this ele gens Tora EE OTHER TAN INDIVIDUALS)
ites,” in idee Pot ih its er irusipeioeure ° ying fs i uired by Bee oper sFieg Warkplace Ad t of 1988, and
el inten 3 oi Eston: OPES ic UaUsgs: as
{fe ation ‘be melgged in fe award doctimenus fa for alPsu arcs
cape a in ub ara oak oct facts under rant Brug PEF RBIRSRE t geptities that it will or will continue to provide a
coaperativ agree ents.” an contracts ae al su
recipients sha ify and AG oe accort fay?
(3) wats mau a uaa noti implo ees that the
law int Fag. grant or
tn
agiue: istribution,
use, OF a cont ince Aonf rantse s
9 ie }
SUSPENS a ainst
Fr gESANIBIEIN BAER ION, AND OTHER mp Byes *S ¥3 sen : 9 Ugh aOR ne . g
(b RR Nee cst aaa drug-free awareness program to
8s te CH ired by. Executive Order, ARPA: oP Panment, A ind
an neigh ie orien He lemented 28 OF RP 6 as defned at cig
eae 187, "SEaKS ion Sr StS (1) The dangers of drugs abuse in the workplace;
y i if intaini -free workplace;
A. The applicant certifies that it and its principals: (2) The grantee’s policy of maintaining a drug-fre! P
(a) Are not presently debarred, suspended, proposed for _debar-
ment ceciared ine lgible. sé sentenced to a denial of Federal
r
benetits by a State or Federal court, or voluntarily excluded from i i
covered By sacle ot by any Federal department or agency; (4) coe penalties that ma PTR ORBL pon employees for drug
3) Al Hable di ling, rehabilitation, and employee
G2 Qahae BIEBIanHgraAaeUneenns: rehabuian ploy
ae Have not v within a hae e-' year Rear receding this appli ication (eelpergtinence Ty Pegrent bs guar" louse to be engaged I
en conyicte ay i civil it ren
commission i a ‘erin ense In confection will
obtaining, a ier ah a Stain: or ina ormning a
(aranranly 2) ie ase Neil of ne pk a nt nde ert ited ap rant,
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
(2 oti ify the employer, in wait
vidlation“of a crimin rug si ule Bog urrin 1p the worl
late ive calendar S al jer such conviction;
rthan
cate ae ae HO Tare stags
wise receiving a tic Convig tion.
eae, i tore Let aks oe fig i u Ing
rograms : ephire eS s gaan i
inclu tide, Hs at A
ng of his or her gonvicticn fora
eee Ss be affected grant
Jaki aking, one. of the erie 8 acti ns, within 58) SFenaat
ays gcelving notice r ragraph
re; pect to any em loyse Wh o'1g'S0 conv
aking ap rij sonnel act tion against suc
boleiee uA in ree aalidiag at 19Y3° stesten wh he
(2 Beauling auch smloves ia eericipste setslatody ine cl
puippees b Sprite naan ato Toe ease Pew v4 ioe suet
free
8.)
(g) Making a good faith effort to continue to maintain a drug
wgrepiace through implementation of paragraphs (a), {b), (€)
e), ani
ahs rantee ma’ insert in t in th e gpace | provided yelow the site
5) for tl eRe ormance done in connection with the
ecific grant:
Pla § of Performance (Street address, city, country, state, zip
El Mirage Police Department
12401 W. Cinnabar Avenue
El Mirage, Arizona 85335
Check [- jfithere are workplace on file that are not identified
euler iret oeeiee fia
Segtis in 67, 630 is ik pans It is
An slet ie Sigel each ap ication
Ise beet atk as Ag He Sfates and State agencies
Check
r if the State has elected to complete OJP Form
4061/7.
ales WAG ARE NDivipuacs)
SIU BAC PR
h :
fe seanenatees Social bata negoaags
ruse at a 1 gontrolfe Substance condi yPactivi y with
B. If convinced of a criminal dru ‘ense resultin: ng. iy fi
violation occurring during the conduct of any grant act ity. wil
cela pms aise oles ln eehats
TN, eoniral Sask. 633 Indiana Avenue, N.W., Wash Arigton
As the duly authorized representative of the applicant, | hereby certify that the applicant will comply with the above certifications.
1. Grantee Name and Address:
El Mirage Police Department
12401 W. Cinnabar Avenue
El Mirage, Arizona 85335
2. .Apptication Number and/or Project Name
3. Grantee IRS/Vendor Number
4. Typed Name and Title of Authorized Representative
5. Signature
6. Date