WPC  77WPC >?d~A?@ ?E: =D?@*D=?+=<,5^oaZб7>   (  (Untitled)'3,, , ,   UB ) 3    *    d +    d ,    d /0ghjklmnopqrstuvwxyz{|}~P* * c:\inf42\forms\ad1052.wpf c:\inf41\phuong\ad1052.wpfUS&& &&   >?df eh Terminal 1 ! d !  d      Terminal eb Arial " ! 2     d    Arial ev Times New Roman  ! 2 F  d    Times New Roman ? Ad A{?z jZ c:\inf41\forest\data\ AD1052.DBFhistory   i%Year     h YEAR i'AState      h ASTATE  i'SState      h SSTATE  i)Address1  r   h ADDRESS1r i)Address2  r   h ADDRESS2r i)Address3  r   h ADDRESS3r i'ChkBox      h CHKBOX  i)AgcyName  q   h AGCYNAMEq i(NmTitle      h NMTITLE  i%Sign      h SIGN i%Date     h DATE ?@d @}?E:R  2 U.S. DEPARTMENT OF AGRICULTURE F !"#                             P  &&    x  2m CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS  2v STATES AND STATE AGENCIES  2 FEDERAL FISCAL YEAR F !"#      n                       P  &&         & This certification is required by the regulations implementing Sections 5151-5160 of the Drug-Free Workplace Act of 1988  & (Pub. L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR Part 3017, Subpart F. The regulations, published as Part II of  & the May 25, 1990 Federal Register (pages 21681-21691), require certification by grantees, prior to award, that they will maintain  & a drug-free workplace. Section 3017.630(c) of the regulation provides that a grantee that is a State may elect to make one  & certification to the Department of Agriculture in each Federal fiscal year in lieu of certificates for each grant during the Federal  & fiscal year covered by the certification. The certificate set out below is a material representation of fact upon which reliance is  & placed when the agency awards the grant. False certification or violation of the certification shall be grounds for suspension  & of payments, suspension or termination of grants, or Governmentwide suspension or debarment (see 7 CFR Part 3017,  & Sections 3017.615 and 3017.620). States and State agencies using this form should send it to: U.S. Department of Agriculture,  & Office of Finance and Management, Federal Assistance and Fiscal Policy Division, Federal Assistance Team, Room 3031  & South Building, Washington, D.C. 20250. F  !"#                             P      g, ,! & 1 9F !"#                             P  &&    ~-," & Form AD-1052 (REV 5/90) <: !"#                             P  &    p. ,# d This form was electronically produced by Elite Federal Forms Inc. 2; !"#                             P  &     ^< 2 (BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3) F !"#                             P  &&    9 Year!"-./546 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&    hJ^^ & A.  !"#                             P  &    J>, & The grantee certifies that it will or will continue to provide a drug-free workplace by:  1 !"#                             P  &    i^^ & (a)   !"#                             P  &     & 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 actions that will be taken against employees for violation of such prohibition;  9 !"#                             P  &    i^^ & (b)    !"#                             P  &    ^ & Establishing an ongoing drug-free awareness program to inform employees about --   7 !"#                             P  &    i^^ & (1)  " !"#                             P  &    : ^ & The dangers of drug abuse in the workplace; " !"#                             P  &    i ^^ & (2)  $ !"#                             P  &    : ^ & The grantee's policy of maintaining a drug-free workplace; $, !"#                             P  &    i~^^ & (3)  % !"#                             P  &    :~ & Any available drug counseling, rehabilitation, and employee assistance  & programs; and %, !"#                             P  &    ir^^ & (4)  ( !"#                             P  &    :r & The penalties that may be imposed upon employees for drug abuse violations  & occurring in the workplace; (, !"#                             P  &    i!^^ & (c)  + !"#                             P  &    ! & 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);  +7 !"#                             P  &    i#^^ & (d)  - !"#                             P  &    # & Notifying the employee in the statement required by paragraph (a) that, as a condition of  & employment under the grant, the employee will --  -7 !"#                             P  &    i%^, & (1)  0 !"#                             P  &    :% , & Abide by the terms of the statement; and 0 !"#                             P  &    i'^, & (2)  2 !"#                             P  &    :', & Notify the employer in writing of his or her conviction for a violation of a 24 !"#                             P  &    ?=d =?@Rp & criminal drug statute occurring in the workplace no later than five calendar days after  & such conviction; 2 !"#                             P  &    ix^, & (e)   !"#                             P  &    @x & Notifying the agency in writing, within ten 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. Notice shall include the  & identification number(s) of each affected grant;  6 !"#                             P  &    i ^, & (f)    !"#                             P  &    @ & & Taking one of the following actions, within 30 calendar days of receiving notice under  & subparagraph (d) (2), with respect to any employee who is so convicted --   6 !"#                             P  &    i@ ^, & (1)   !"#                             P  &    3   & 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; or 1 !"#                             P  &    i@^, & (2)   !"#                             P  &    [  & 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; 1 !"#                             P  &    i^, & (g)   !"#                             P  &    @& & Making a good faith effort to continue to maintain a drug-free workplace through implementation  & of paragraphs (a), (b), (c), (d), (e) and (f).  6 !"#                             P  &    J & This certification is for a  &i (check one)  !"#                             P  &     J & State (All State  & Agencies)   AState#$%&' ()+,-.                             P   !  * <& 1  2      3       @RESETOBJ (SState)   SState    Jl^ & Single State Agency   SState#$%,&'()+,-.                             P   !  * <& 1  2      3       @RESETOBJ (AState)   AState    hp^, & B.  !"#                             P  &    p& & The grantee may insert in the space provided below the site(s) for the performance of work done in  & connection with the specific grant:  ; !"#                             P  &    $^ & Place of Performance (Street address, city, county, State, zip code)  ( !"#                             P  &    ; ^  Address1!"-./56"7F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && =      k , & Check ) !"#                             P  &    -F >, & if there are workplaces on file that are not identified above.   ChkBox#$% &)'1()+,-.                             P   !  * <& 1  2      3       @RESETOBJ (AState)   AState    _! & } State / State Agency Name AgcyName!"-./56+7F89:F;>?@ABCG                         P #      $      ' q  Y@$.,! *  < &0 = &     p# X } Name and Title of Authorized Representative NmTitle!"-./56.7F89:F;>?@ABCG                         P #    Z  $    Z  '  q  Y@$.,!j *  < &0 = &     KH&& } Signature Sign! "-./5617*89:*;>?@ABCG                         P #      $      '  K  Y@$.,! *  < &0 = &     HpH& & } Date Date! "-./5261789:;>?@ABCG                         P #      $      ' K  Y@$.,! *  < &0 = &     2@HASVALUE (Date) and #UPDATONLY    Date  ~      7@datevalue (@datetext (Date, "%2-%1-%5"))   Date   %2-%1-%5  "  #  4@VALUE (@DATETEXT (Date,"%5"))<=29   Date   %5  "  x         p@SETVALUE (Date, @DATEVALUE (@CONCAT (@DATETEXT (Date,"%2-%1"),"-20",@DATETEXT (Date,"%5"))),TRUE)   Date   Date   %2-%1  "   -20   Date   %5  "      #       h) , & Please append to this form a list of any State agencies the Governor has excluded from this certification. 5F !"#                             P  &    g, , & 2 9F !"#                             P  &&    ~-, & Form AD-1052 (REV 5/90) <: !"#                             P  &    ; ^  Address2!"- ./56$7F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && =      ; ^  Address3!"- ./56'7F89:;>?@ABCG                         P #    d  $    d  ' r  Y@$.,! *  < && =      ?*=d =?+R  2> INSTRUCTIONS FOR CERTIFICATION F !"#                             P  &&    hF^ & 1.  !"#                             P  &    F & By signing and submitting this form, the grantee is providing the certification set out on pages 1 and 2.  > !"#                             P  &    h^ & 2.  !"#                             P  &    J & The certification set out pages 1 and 2 is a material representation of fact upon which reliance is placed when  & the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification,  & or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other  & remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.  > !"#                             P  &    h" ^ & 3.  !"#                             P  &    " ~ & Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If  & known, they may be identified in the grant application. If the grantee does not identify the workplaces at the  & time of application, or upon award, if there is no application, the grantee must keep the identity of the  & workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all  & known workplaces constitutes a violation of the grantee's drug-free workplace requirements.  > !"#                             P  &    h^ & 4.  !"#                             P  &      & Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites  & where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass  & transit authority or State highway department while in operation, State employees in each local unemployment  & office, performers in concert halls or radio studios).  > !"#                             P  &    hV^ & 5.  !"#                             P  &    NV& & If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform  & the agency of the change(s), if it previously identified the workplaces in question (see paragraph three).  > !"#                             P  &    h^ & 6.  !"#                             P  &    p  & Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free  & Workplace common rule apply to this certification. Grantees' attention is called, in particular, to the following  & definitions from these rules:  > !"#                             P  &    8X & "Controlled substance" means a controlled substance in Schedules I through V of the Controlled  & Substances Act (21 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);  9 !"#                             P  &    nX & "Conviction" means a finding of guilt (including a plea of nolo contendere) or imposition of sentence,  & or both, by any judicial body charged with the responsibility to determine violations of the Federal or  & State criminal drug statutes;  #9 !"#                             P  &     F& & "Criminal drug statute" means a Federal or non-Federal criminal statute involving the manufacture,  & distribution, dispensing, use, or possession of any controlled substance;  &9 !"#                             P  &    yl   & "Employee" means the employee of a grantee directly engaged in the performance of work under a  & grant, including; (i) all "direct charge" employees; (ii) all "indirect charge" employees unless their  & impact or involvement is insignificant to the performance of the grant; and, (iii) temporary personnel  & and consultants who are directly engaged in the performance of work under the grant and who are on  & the grantee's payroll. This definition does not include workers not on the payroll of the grantee (e.g.,  & volunteers, even if used to meet a matching requirement; consultants or independent contractors not  & on the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces).  )9 !"#                             P  &    g- ,  & 3 9F !"#                             P  &&    ~-,  & Form AD-1052 (REV 5/90) <: !"#                             P  &    ?N=d =<,defgh i <^o elite10.DLL IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. elite10.COM IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. WPIN$ELITE10FunctionSet,4.1 ^=Zы4}!ZS