Signing this form certifies compliance with the federal statutes and regulations cited below. It is your contract with the Wisconsin Department of Public Instruction while implementing a federal grant.
§3187 Adoption of 2 CFR Part 200: Institute of Museum and Library Services (IMLS). The authorized representative, on behalf of the applicant, certifies that the applicant will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 (31 U.S.C. §7501 et seq.) and OMB Circular No. A-133, "Audits of States, Local Governments, and Non-Profit Organizations." The authorized representative, on behalf of the applicant, certifies that the applicant will comply with the provisions of applicable OMB Circulars.
DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
As required by Executive Order 12549 and implemented at 2 C.F.R. Part 3185, the undersigned, on behalf of the applicant, certifies to the best of his or her knowledge and belief that neither the applicant, nor its principals:
(a) are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency;
(b) have within a three year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction, or in connection with a violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
(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 enumerated in paragraph (b) of this certification;
(d) have within a three-year period preceding this application/proposal had one or more public transactions (federal, state, or local) terminated for cause or default. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this application.
DRUG FREE WORKPLACE REQUIREMENTS
As required by the Drug Free Workplace Act of 1988 and implemented at 2 C.F.R. Part 3186, the undersigned, on behalf of the applicant, certifies that the applicant will or will continue to 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 grantee's workplace and specifying the action that will be taken against employees for violation of such prohibition;
(b) establishing an ongoing drug free awareness program to inform employees about:
- the dangers of drug abuse in the workplace;
- the grantee's policy of maintaining a drug free workplace;
- any available drug counseling, rehabilitation, and employee assistance programs; and
- the penalties that may be imposed on 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 grant 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
(1) abide by the terms of the statement; and
(2) notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace not later than five calendar days after such conviction;
(e) notifying the agency in writing within ten (10) calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer on whose grant activity the convicted employee was working, unless the federal agency has designated a central point for the receipt of such notices. Notices shall include the identification number(s) of each affected grant;
(f) taking one of the following actions within thirty (30) days of receiving notice under subparagraph (d)(2) with respect to any employee who is so convicted:
(1) taking appropriate personnel action against such an employee, up to and including termination consistent with the requirements of the Rehabilitation Act of 1973, as amended (29 U.S.C. § 701 et seq.); or
(2) 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 or other appropriate agency;
(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). The applicants either shall identify the site(s) for the performance of work done in connection with the project in the application material or shall keep this information on file in its office so that it is available for federal inspection. The street address, city, county, state, and zip code should be provided whenever possible.
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 applicant 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 applicant) 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. State Programs 3 Issued 2/9/2006.
(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.
FEDERAL DEBT STATUS
The undersigned, on behalf of the applicant, certifies to the best of his or her knowledge and belief that the applicant is not delinquent in the repayment of any federal debt.
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 1110.4, the undersigned, on behalf of the applicant, certifies that the applicant 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.
INTERNET SAFETY (CIPA) PUBLIC ELEMENTARY AND SECONDARY SCHOOL LIBRARIES, and CONSORTIA WITH PUBLIC AND/OR PUBLIC SCHOOL LIBRARIES
The library is either:
A. CIPA Compliant (The applicant library has complied with the requirements of Section 9134(f) (1) of the Library Services and Technology Act - LSTA)
B. CIPA requirements do not apply because LSTA funds are NOT being used to purchase computers to access the Internet, or to pay for direct costs associated with accessing the Internet.
TRAFFICKING IN PERSONS
The SLAA must comply with Federal law pertaining to trafficking in persons. Under 22 U.S.C. § 7104(g), any grant, contract, or cooperative agreement entered into by a Federal agency and a private entity shall include a condition that authorizes the Federal agency (IMLS) to terminate the grant, contract, or cooperative agreement, if the grantee, subgrantee, contractor, or subcontractor engages in trafficking in persons, procures a commercial sex act, or uses forced labor. 2 C.F.R. part 175 requires IMLS to include the following award term:
a. Provisions applicable to a recipient that is a private entity.
1. You as the recipient, your employees, subrecipients under this award, and subrecipients' employees may not -
i. Engage in severe forms of trafficking in persons during the period of time that the award is in effect;
ii. Procure a commercial sex act during the period of time that the award is in effect; or
iii. Use forced labor in the performance of the award or subawards under the award.
2. We as the Federal awarding agency may unilaterally terminate this award, without penalty, if you or a subrecipient that is a private entity -
i. Is determined to have violated a prohibition in paragraph a.1 of this award term; or
ii. Has an employee who is determined by the agency official authorized to terminate the award to have violated a prohibition in paragraph a.1 of this award term through conduct that is either -
A. Associated with performance under this award; or
B. Imputed to you or the subrecipient using the standards and due process for imputing the conduct of an individual to an organization that are provided in 2 C.F.R. part 180, "OMB Guidelines to Agencies on Government-wide Debarment and Suspension (Nonprocurement)," as implemented by our agency at 2 C.F.R. part 3185.
b. Provision applicable to a recipient other than a private entity. We as the Federal awarding agency may unilaterally terminate this award, without penalty, if a subrecipient that is a private entity -
1. Is determined to have violated an applicable prohibition in paragraph a.1 of this award term; or
2. Has an employee who is determined by the agency official authorized to terminate the award to have violated an applicable prohibition in paragraph a.1 of this award term through conduct that is either -
i. Associated with performance under this award; or
ii. Imputed to the subrecipient using the standards and due process for imputing the conduct of an individual to an organization that are provided in 2 C.F.R. part 180, "OMB Guidelines to Agencies on Government-wide Debarment and Suspension (Nonprocurement)," as implemented by our agency at 2 C.F.R. part 3185.
c. Provisions applicable to any recipient.
1. You must inform us immediately of any information you receive from any source alleging a violation of a prohibition in paragraph a.1 of this award term. 2. Our right to terminate unilaterally that is described in paragraph a.2 or b of this section:
i. Implements section 106(g) of the Trafficking Victims Protection Act of 2000 (TVPA), as amended (22 U.S.C. § 7104(g)), and
ii. Is in addition to all other remedies for noncompliance that are available to us under this award.
3. You must include the requirements of paragraph a.1 of this award term in any subaward you make to a private entity. d. Definitions. For purposes of this award term:
1. "Employee" means either: i. An individual employed by you or a subrecipient who is engaged in the performance of the project or program under this award; or
ii. Another person engaged in the performance of the project or program under this award and not compensated by you including, but not limited to, a volunteer or individual whose services are contributed by a third party as an in-kind contribution toward cost sharing or matching requirements.
2. "Forced labor" means labor obtained by any of the following methods: the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.
3. "Private entity": i. Means any entity other than a State, local government, Indian tribe, or foreign public entity, as those terms are defined in 2 C.F.R. part 175.25.
A. A nonprofit organization, including any nonprofit institution of higher education, hospital, or tribal organization other than one included in the definition of Indian tribe at 2 C.F.R part 175.25(b).
B. A for-profit organization.
4. "Severe forms of trafficking in persons," "commercial sex act," and "coercion" have the meanings given at section 103 of the TVPA, as amended (22 U.S.C. § 7102). —2 C.F.R. part 175.15, Electronic Code of Federal Regulations , as of July 6, 2015.
IMLS grantees and subgrantees are required to comply with Title IX, which protects against discrimination based on sex in education programs that receive Federal financial assistance. Recent cases, both in employment discrimination law and under state constitutional law, afford similar protections for transgender individuals.
I, THE UNDERSIGNED, CERTIFY that the 2017 project(s) will be the basis for the operation and administration for which LSTA funds are requested. We will provide expenditure and other reports and will comply with such fiscal provisions as the DLT requires. We will comply with the statutes and regulations cited above as required by the Institute of Museum and Library Services (IMLS).
Applicant Library or System
Federal Funds Requested:
Name of Principal Officer of Applicant Agency______________________________
Title of Principal Officer _____________________________
Signature of Principal Officer___________________________
Date Signed Mo./Day/Yr. _____________________________
Print this page, sign, SCAN and attach no later than October 14, 2016 by email to: (Teresa.Howe@dpi.wi.gov) OR
Print this page, sign, and return by mail postmarked by October 14, 2016. Send signed page to:
Terrie Howe, LSTA Program Coordinator
Wisconsin Department of Public Instruction
Division for Libraries and Technology
PO Box 7841
Madison, WI 53707-7841