HomeMy WebLinkAboutCertification re USDA JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
CONSENT AGENDA REQUEST
TO: Board of County Commissioners
FROM: Amanda Christofferson,Grants Administrator
Kate Dean,Commissioner District No. 1
DATE: June 24,2024
SUBJECT: Certifications and Agreements for Signature by BOCC requirement of the
Congressionally Directed Spending(CDS)for the Early Learning and Family
Support Center
STATEMENT OF ISSUE:
As a requirement for the CDS funding allocated for the Early Learning and Family Support Center which is
being managed by USDA the county must certify their compliance and agree to uphold various federal laws
and obligations.
ANALYSIS:
This package of certifications required by the USDA as a part of receipt of Federal Funding has been
reviewed by Risk and Legal.
FISCAL IMPACT:
The successful application for this funding will result in a 1.375million grant to the county for the purpose of
building the Early Learning and Family Support Center.
RECOMMENDATION:
Staff requests the Board approve a motion to sign the attached certifications and agreements asscciated with
the CDS for the Early Learning and Family Support Center.
REVIEWED BY:
Mark McCauley ounty Administrator Date
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: USDA Contract No: RC 400-4/RD 400-1
Contract For: Federal Award of 1.375 million Term:
COUNTY DEPARTMENT: Auditor
Contact Person: Amanda ChnstoIIerson,Grant Administrator
Contact Phone: 360-385-9232
Contact email: amchristonenson@co.iefferson.wa.us
AMOUNT: 1.375 million PROCESS: Exempt from Bid Process
Revenue: 1.375 million(grant) Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s)of Matching Funds Vendor List Bid
Fund# 123 RFP or RFQ
Munis Org/Obj 12333110.331001 Other:Agreement
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES C LIANCE WITH [CC 3.55.080 AND CHAPTER 42.23 RCW.
CERTIFIED: ❑ N/A:a CA
Signature U J Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: ❑ N/A: a
Signat ate
STEP 3: RISK MANAGEMENT REVIEW(will he added electronically through Laserfiche):
Electronically approved by Risk Management on 6/20/2024.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 6/20/2024.
Federal langauge - cannot change. Thanks for signing the certification
and adding the required signature blocks for PAO approval.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
I
OMB APPROVAL NO.
9000 - 0101
U.S. DEPARTMENT OF AGRICULTURE
CERTIFICATION REGARDING
DRUG-FREE WORKPLACE REQUIREMENTS(GRANTS)
ALTERNATIVE I - FOR GRANTEES OTHER THAN INDIVIDUALS
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, Section 3017.600, Purpose. The regulations were published as Part II of
the January 31,1989 Federal Register (pages 4947-4952) . Copies of the regulations may be
obtained by contacting the Department of Agriculture agency offering the grant.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
Alternative I
(A) The grantee 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 grantee'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 --
(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon 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
Form AD-1049 (REV 2-89)
i
(2) Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five days after such conviction;
(a) Notifying the agency within ten days after receiving notice under subparagraph (d) (2)
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) (2) , with respect to any employee who is so convicted --
(1) Taking appropriate personnel action against such an employee, up to and including
termination; 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 enforcement, 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) .
B. The grantee shall insert in the space provided below the site(s) for the performance of work
done in connection with the specific grant.
Place of Performance (Street address, city, county, State, zip code)
1500 Van Ness Street, Port Townsend, WA 98368
Jefttraor. County Early Learning and
Jefferson County Fam_ly Suoport Center
4rg[anixoti4n Name PR/Award Number or Project Name
Kate Dean, Jefferson County Commissioner
Name and Title of Authorized Representative
Signature Date APP.—rd se M f—Le'
C 4
June 20,2024
INSTRUCTIONS FOR CERTIFICATION '
1. By signing and submitting this form, the grantee is providing the certification set out on
pages 1 and 2.
2. The certification met out on pages 1 and 2 is a material representation of fact upon which
reliance was placed when the agency determined to award 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.
Form AD-1049(RKV 2-89)
i
Conflict of Interest
Processing and Servicing Rural Development Assistance
To Employees, Relatives and Associates
To assure the high standards of honesty, integrity, and impartiality maintained by Rural Development
employees,we need to identify any Rural Development assistance to be provided to Rural Development
employees,their relatives,or their business or close personal associates. This includes unsured or
guaranteed, loan or grants,to individuals or organizations. If you know of any relationship or
association you may have with a Rural Development employee, please notify the local Rural
Development office processing your application. Your response will allow us to make special provisions
for processing but will not affect your application status.
Identify any relative or close associate as listed above or type"none"as applicable.
None
Jefferson County
Name of Organization/Applicant
Kate Dean,County Commissioner
Name of Authorized Official
Signature Date
App`.,-.rd as to form onh
0 C June 20,2024
PhiLp C li o kc. Dace
Chef Cr.A Depur.R�wmng ku—
Form RD 400-1 FORM APPROVED
(Rev.8-22) UNITED STATES DEPARTMENT OF AGRICULTURE OMB No.0575-0201
Exp.Date:07/31/2025
EQUAL OPPORTUNITY AGREEMENT
This agreement,dated June 17th,2024 between
Jefferson County
(herein called"Recipient"whether one or more)and United States Department of Agriculture(USDA),pursuant to the rules and
regulations of the Secretary of Labor(herein called the'Secretary')issued under the authority of Executive Order 11246 as amended,
witnesseth:
In consideration of financial assistance(whether by a loan,grant,loan guaranty,or other form of financial assistance)made or to be
made by the USDA to Recipient,Recipient hereby agrees,if the cash cost of construction work performed by Recipient or a construction
contract financed with such financial assistance exceeds$10,000-unless exempted by rules,regulations or orders of the Secretary of
Labor issued pursuant to Section 204 of Executive Order 11246 of September 24, 1965.
1. To incorporate or cause to be incorporated into any contract for construction work,or modification thereof,subject to the
relevant rules,regulations,and orders of the Secretary or of any prior authority that remain in effect,which is paid for in whole or in part
with the aid of such financial assistance,the following"Equal Opportunity Clause":
During the performance of this contract,the contractor agrees as follows:
(a)The contractor will not discriminate against any employee or applicant for employment because of race,color,religion,sex or
national origin.The contractor will take affirmative action to ensure that applicants are employed,and that employees are
treated during employment,without regard to their race,color,religion,sex or national origin.Such action shall include,but
not be limited,to the following:employment,upgrading,demotion or transfer;recruitment or recruitment advertising;layoff
or termination;rates of pay or other forms of compensation;and selection for training,including apprenticeship.The contractor
agrees to post in conspicuous places,available to employees and applicants for employment,notices to be provided by the
USDA setting forth the provisions of this nondiscrimination clause.
(b)The contractor will,in all solicitations or advertisements for employees placed by or on behalf of the contractor,state that all
qualified applicants will receive consideration for employment without regard to race,color,religion,sex or national origin.
(c)The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement
or other contract or understanding,a notice,to be provided by the USDA,advising the said labor union or workers'
representative of the contractor's commitments under this agreement and shall post copies of the notice in conspicuous places
available to employees and applicants for employment.
(d)The contractor will comply with all provisions of Executive Order 11246 of September 24,1965,and of all rules,regulations
and relevant orders of the Secretary of Labor.
(e)The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965,rules,
regulations,and orders,or pursuant thereto,and will permit access to his books,records,and accounts by the USDA Civil
Rights Office,and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules,
regulations,and orders.
(f) In the event of the contractor's noncompliance with the nondiscrimination clauses of this contract or with any of the said rules,
regulations,or orders,this contract may be cancelled,terminated,or suspended in whole or in part and the contractor may be
declared ineligible for further Government contracts or federally assisted construction contracts in accordance with procedures
authorized in Executive Order No. 11246 of September 24, 1965,and such other sanctions may be imposed and remedies
invoked as provided in Executive Order No. 11246 of September 24, 1965,or by rule,regulation or order of the Secretary of
Labor,or as otherwise provided by Law.
(g)The contractor will include the provisions of paragraph 1 and paragraph(a)through(g)in every subcontract or purchase order,
unless exempted by the rules,regulations,or orders of the Secretary of Labor issued pursuant to Section 204 of Executive Order
No. 11246 of September 24, 1965,so that such provisions will be binding upon each subcontractor or vendor.The
contractor will take such action with respect to any subcontract or purchase order as the USDA may direct as a means of
enforcing such provisions,including sanctions for noncompliance:Provided,however,that in the event the contractor becomes
involved in,or is threatened with,litigation with a subcontractor or vendor as a result of such direction by the USDA,the
contractor may request the United States to enter into such litigation to protect the interest of the United States.
According to the Paperwork Reduction Act of 1995,an agency may not conduct or sponsor,and a person is not required to respond
to,a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collections is 0575-00I& The time required to complete this information collection is estimated to average 10 minutes r response,
including the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed and
completing and reviewing the collection of information.
Position 6 RD 400-1 (Rev.5-00)
2. To be bound by the above equal opportunity clause with respect to its own employment practices when it participates in federally
assisted construction work:Provided,that if the organization so participating is a State or local government,the above equal
opportunity clause is not applicable to any agency,instrumentality or subdivision of such government which does not participate in
work on or under the contract.
3. To notify all prospective contractors to file the required'Compliance Statement',Form RD 400-6,with their bids.
4. Form AD425,Instructions to Contractors,will accompany the notice of award of the contract. Bid conditions for all nonexempt
federal and federally assisted construction contracts require inclusion of the appropriate"Hometown"or"Imposed"plan affirmative
action and equal employment opportunity requirements.All bidders must comply with the bid conditions contained in the invitation to
be considered responsible bidders and hence eligible for the award.
5. To assist and cooperate actively with USDA and the Secretary in obtaining the compliance of contractors and subcontractors with
the equal opportunity clause and rules,regulations,and relevant orders of the Secretary,that will furnish USDA and the Secretary such
information such as,but not limited to,Form AD-560,Certification of Nonsegregated Facilities,to submit the Monthly Employment
Utilization Report,Form CC-257,as they may require for the supervision of such compliance,and that it will otherwise assist USDA in
the discharge of USDA's primary responsibility for securing compliance.
6. To refrain from entering into any contract or contract modification subject to such Executive Order 11246 of September 24, 1965,
with a contractor debarred from,or who has not demonstrated eligibility for,Government contracts and Federally assisted construction
contracts pursuant to the Executive Order and will carry out such sanctions and penalties for violation of the equal opportunity clause as
may be imposed upon contractors and subcontractors by USDA or the Secretary of Labor pursuant to Part 11,Subpart D,of the
Executive Order.
7. That if the recipient fails or refuses to comply with these undertakings,the USDA may take any or all of the following actions:
Cancel,terminate,or suspend in whole or in part this grant(contract,loan,insurance,guarantee►:refrain from extending any further
assistance to the organization under the program with respect to which the failure or refund occurred until satisfactory assurance of
future compliance has been received from such organization,and refer the case to the Department of Justice for appropriate legal
proceedings.
Signed by the Recipient on the date first written above.
Recipient Recipient
Jefferson County
(CORPORATE SEAL) Name of Corporate Recipient
Attest:
By
Secretary President
I
Appro%ed as to form onl}
O C hQW- June 20,2024
Philip C.Hwxwker, Date
Chief Cr:ff Depart•Prosecuun¢Attornev
FORM APPROVED
USDA OMB No. 0575-0201
Form RD 400-4 Position 3 Exp.Date:07/31/2025
(Rev.08-22)
ASSURANCE AGREEMENT
(Under Title VI,Civil Rights Act of 1964)
The Jefferson County
(name of recipient)
PO Box 563 Port Townsend,WA 98368-
(address)
As a condition of receipt of Federal financial assistance,you acknowledge and agree that you must comply(and require any
subgrantees,subrecipients,contractors,successors,transferees,and assignees to comply)with applicable provisions of national
laws and policies prohibiting discrimination,including but not limited to:
1. Title VI of the Civil Rights Act of 1964,as amended,which prohibits you from discriminating on the basis of race,
color,or national origin(42 U.S.C.2000d et seq.),and 7 CFR Part 15,7 CFR 1901,Subpart E.
As clarified by Executive Order 13166,Improving Access to Services for Persons with Limited English Proficiency,and
resulting agency(Rural Housing Service,Rural Business and Cooperative Service,and Rural Utilities Service)guidance,
national origin discrimination includes discrimination on the basis of limited English proficiency(LEP).To ensure
compliance with Title VI,you must take reasonable steps to ensure that LEP persons have meaningful access to your
programs[in accordance with USDA RD LEP Guidance for RD Funded(Assisted)Programs].Meaningful access may
entail providing language assistance services,including oral and written translation,where necessary.You are encouraged
to consider the need for language services for LEP persons served or encountered both in developing your budgets and in
conducting your programs and activities.For assistance and information regarding your LEP obligations,go to
htti)://www.lep.pov;
2. Title IX of the Education Amendments of 1972,as amended,which prohibits you from discriminating on the basis of
sex in education programs or activities(20 U.S.C. 1681 et seq.)[as implemented by 7 CFR Part 15,7 CFR 1901,Subpart
E];
3. The Age Discrimination Act of 1975,as amended,which prohibits you from discriminating on the basis of age
(42 U.S.C.6101 et seq.)[as implemented by 7 CFR Part 15,7 CFR 1901,SubpartE];
4. Section 504 of the Rehabilitation Act of 1973,as amended,which prohibits you from discriminating on the basis of
disability(29 U.S.C.794)[as implemented by 7 CFR Part 15,7 CFR Part 15b,7 CFR 1901,Subpart E];
5. Title VIII of the Civil Rights Act,which prohibits you from discriminating in the sale,rental,financing,and
advertising of dwellings,or in the provision of services in connection therewith,on the basis of race,color,national
origin,religion,disability,familial status,and sex(42 U.S.C.3601 et seq.),as implemented by the Department of
Housing and Urban Development at 24 CFR part 100.The prohibition on disability discrimination includes the
requirement that new multifamily housing with four or more dwelling units,i.e.,the public and common use areas and
individual apartment units(all units in buildings with elevators and ground-floor units in buildings without elevators)be
designed and constructed with certain accessible features,see 24 CFR Part 100.201;and
6. Titles II and III of the Americans with Disabilities Act,which prohibit you from discriminating on the basis of
disability in the operation of public entities,public and private transportation systems,places of public accommodation,
and certain testing entities(42 U.S.C.§§ 12131-12189).as implemented by Department of Justice regulations at28
C.F.R.parts 35 and 36,and 7 CFR Part 15,7 CFR Part 15b,7 CFR 1901,Subpart E.
According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB
control number for this information collection is 0575-0018.The time required to complete this information is estimated to average 15 minutes per response,including the time for
reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and rewe.ring the collection of information.
You also acknowledge and agree that you must comply(and require any subgrantees,subrecipients,contractors,successors,
transferees,and assignees to comply)with applicable provisions governing USDA Rural Development(Rural Housing Service,
Rural Business and Cooperative Service,and Rural Utilities Service)access to records,accounts,documents,information,
facilities,and staff:
I. You must cooperate with any compliance review or complaint investigation conducted by USDA Rural Development
(Rural Housing Service,Rural Business and Cooperative Service,and Rural Utilities Service).
2. You must give USDA Rural Development(Rural Housing Service,Rural Business and Cooperative Service,and Rural
Utilities Service)access to and the right to examine and copy records,accounts,and other documents and sources of
information related to the grant and permit access to facilities,personnel,and other individuals and information as may
be necessary,as required by Title VI,Title IX,Age,and Section 504 implementing regulations and other applicable
laws or program guidance.
3. You must keep such records and submit to the responsible Department official or designee timely,complete,and
accurate compliance reports at such times,and in such form and containing such information,as the responsible
Department official or his designee may determine to be necessary to ascertain whether you have complied or are
complying with relevant obligations.
4. You must comply with all other reporting,data collection,and evaluation requirements,as prescribed by law or detailed
in program guidance.
5. Make available to users,participants,beneficiaries and other interested persons such information regarding the
provisions of this agreement and the regulations,and in such manner as the Rural Development or the U.S.Department
of Agriculture finds necessary to inform such persons of the protection assured them against discrimination.
6. If,during the past three years,you(the recipient)have been accused of discrimination on the grounds of race,color,
national origin(including limited English proficiency),sex,age,disability,religion,or familial status,you must provide
a list of all such proceedings,pending or completed,including outcome and copies of settlement agreements.
7. In the event any court or administrative agency makes a finding of discrimination on grounds of race,color,national
origin(including limited English proficiency),sex,age,disability,religion,or familial status against you,or you settle a
case or matter alleging such discrimination,you must forward a copy of the complaint and findings to USDA Rural
Development(Rural Housing Service,Rural Business and Cooperative Service,and Rural Utilities Service),Office of
Civil Rights.
The United States has the right to seek judicial enforcement of these obligations.
You also acknowledge and agree that you must comply(and require any subgrantees,subrecipients,contractors,successors,
transferees,and assignees to comply)with applicable provisions of program-specific nondiscrimination policy requirements found
at CFR Part 15,7 CFR Part 15 b, 12 CFR Part 202,7 CFR 1901,Subpart E.,DR4300-003,DR4330-0300,DR4330-005.
Period of Obligation
In the case of any service,financial aid,covered employment,equipment,property,or structure provided,leased,or improved with
federal assistance extended to the Recipient by Rural Development(Rural Housing Service,Rural Business and Cooperative
Service,and Rural Utilities Service),this assurance obligates the Recipient for the period during which federal assistance is
extended.In the case of any transfer of such service,financial aid,equipment,property,or structure,this assurance obligates the
transferee for the period during which federal assistance is extended.If any personal property is so provided,this assurance obligates
the Recipient for the period during which it retains ownership or possession of the property.In all other cases,this assurance
obligates the Recipient for the period during which the federal assistance is extended to the Recipient by Rural Development(Rural
Housing Service,Rural Business and Cooperative Service,and Rural Utilities Service).
Employment Practices
Where a primary objective of the federal assistance is to provide employment or where the Recipient's employment practices affect
the delivery of services in programs or activities resulting from federal assistance extended by Rural Development(Rural Housing
Service,Rural Business and Cooperative Service,and Rural Utilities Service),the Recipient agrees not to discriminate on the
grounds of race,color,national origin,sex,age,or disability,in its employment practices.Such employment practices may include,
but are not limited to,recruitment,advertising,hiring,layoff or termination,promotion,demotion,transfer,rates of pay,training and
participation in upward mobility programs;or other forms of compensation and use of facilities.
Data Collection
The Recipient agrees to compile and maintain information pertaining to programs or activities developed as a result of the
Recipient's receipt of federal assistance from Rural Development(Rural Housing Service,Rural Business and Cooperative Service,
and Rural Utilities Service).Such information shall include,but is not limited to the following:(1)the manner in which services are
or will be provided and related data necessary for determining whether any persons are or will be denied such services on the basis
of prohibited discrimination;(2)the population eligible to be served by race,color,national origin,sex,age,and disability;(3)data
regarding covered employment including use or planned use of bilingual public contact employees serving beneficiaries of the
program where necessary to permit effective participation by beneficiaries unable to speak or understand English;(4)the location of
existing or proposed facilities connected with the program and related information adequate for determining whether the location has
or will have the effect of unnecessarily denying access to any person on the basis of prohibited discrimination;(5)the present or
proposed membership by race,color,national origin,sex,age and disability in any planning or advisory body which is an integral
part of the program;and(6)any additional written data determined by Rural Development(Rural Housing Service,Rural Business
and Cooperative Service,and Rural Utilities Service)to be relevant to the obligation to assure compliance by recipients with laws
cited in this assurance agreement.
Under penalty of perjury,the undersigned officials certify that they have read and understand their obligations as herein described,
that the information submitted in conjunction with this Document is accurate and complete.and that the recipient is in compliance
i
with the nondiscrimination requirements set out above.
Rights and remedies provided for under this agreement shall be cumulative.
I
In witness whereof, .JeffePSon County on this
(name of recipient)
date has caused this agreement to be executed by its duly authorized officers and its seal affi xed hereto,or,if a natural person,has
hereunto executed this agreement.
(S E A L) Recipient
Date
I
Attest: Kate Dean,County Commissioner,Chair
Carolyn Gallaway,CMC,Clerk of the Boa Title
Title
Approved as to form one}
tom` .
0 C June 20,2024
PhLhp C Humucker. Date
Ctuef Cn d Deputy Prosecuting Attonw%
USDA-RD Position 3
Form RD 1910-11
(Rev.9-02) UNITED STATES DEPARTMENT OF AGRICULTI RE
RURAL DEVELOPMENT
APPLICANT CERTIFICATION
FEDERAL COLLECTION POLICIES FOR CONSUMER OR COMMERCIAL DEBTS
The Federal Government is authorized to check credit information about the applicant(s)including using the federal Credit Alert Interactive
Voice Response System(CAIVRS)or its successors to check to see if the applicant(s)are delinquent or in default on a Federal debt.
The Federal Government is also authorized by law to take any or all of the following actions in the event your loan payments become
delinquent or you default on your loan:
Report your name and account information to a credit reporting agency,and the Credit Alert Interactive Voice Response
System(CAIVRS).
• Assess interest and penalty charges for the period of time that payment is not made.
• Assess charges to cover additional administrative costs incurred by the government to service your account.
• Offset amounts to be paid to you from your Federal income tax refund.
• Offset amounts to be paid to you under other Federal Programs.
• Refer your account to a private collection agency to collect the amount due.
• Foreclose on any security you have given for the loan.
• Pursue legal action to collect through the courts.
• Report any written off debt to the Internal Revenue Service as taxable income.
• If you are a current or retired Federal employee,take action to offset your salary.or civil service retirement benefits.
• Debar or suspend you from doing business with the Federal Government either as a participant or principal throughout the
executive branch of the Federal Government for the period of debarment or suspension.
• Refer any debt that is delinquent to the Treasury Offset Program(TOP)in accordance with the Debt Collection
Improvement Act of 1996.
• Refer any eligible debt that is delinquent to the Treasury for cross servicing in accordance with the Debt Collection
Improvement Act of 1996.
• Garnish your wages as allowed by the Debt Collection Improvement Act of 1996.
Any or all of these actions may be used to recover any debts owed when it is determined to be in the interest of the Government to do so.
CERTIFICATION:I/we have read and I/we understand the actions the Federal Government may take in the event that I/we fail to meet
my/our scheduled payments in accordance with the terms and conditions of my/our agreement. I/we understand that the above list is not
all inclusive and that the Federal Government may deem additional actions necessary to collect should Pvve become delinquent.
(Signature-Individual(s)) (Date) (Signature-Individual t s)) (Date)
i
j ----------------------------------------------- -----------------------
(Date) Jefferson County
(SEAL) (Name of Applicant)
(Signature of Authorized Entity Official)
ATTEST: Kate Dean, County C_vmiestoner, Chair
Il"itle of Authorized Entity Official)
PO Box 563
(Signature of Attesting Official) (Address)
Carolyn Gallaway, CMC, Clerk of the Boar Port Townsend, WA 98368-
(Title of Attesting Official) (City.State.and Zip Code)
Appw ed�.,,.f—-K
0 C June_20,2024 RD 1910-11(Rev.9-02)
('E,e(Cr 17eo.m Prc.armu•a�em..
RD Instruction 1940-Q
Exhibit A-1
CERTIFICATION FOR CONTRACTS, GRANTS AND LOANS
The undersigned certifies, to the best of his or her --.now-'edge and belief,
that:
:. No Federal appropriated funds have been paid or :sill 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 >f Congress, an
officer or employee of Congress, or an employee of a Memb=,r of Congress in
connection with the awarding of any Federal contract, the making of any
Federal grant or Federal loan, and the extension, continuition, renewal,
amendment, or modification of any Federal contract, grant or -oan.
2 If any funds other than Federal appropriated fur: 9s have been paid or
will be paid to any person for influencing or attempting -.o i:fluence an
officer or employee of any agency, a Member of Congress, to officer or
employee of Congress, or an employee of a Member of Congr-iss in connection
with this Federal contract, grant or loan, the undersignei shall complete and
submit Standard Form - LLL, ' 'Disclosure of Lobbying Activities,- in accordance
with its instructions.
3 The undersigned shall require that the 'Language >f tnis certification
be included in the award documents for all subawards at a: 1 tiers (including
contracts, subcontracts, and subgrants under grants and 1_ ans! and that all
subrecipients shall certify and disclose accordingly.
This certification is a material representation of fa a upon which
reliance was placed when this transaction was made or enc !red into.
Submission of this certification is a prerequisite for ma-ting 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 subjec* to a civil penalty
of not less than $10,000 and not more than $10C,000 for etch z3uch failure.
:tte)
Kate Dean,(minty Commissioner,Chair
ruts
Appro�ed as to form onh
June 20,2024 pN 171
Pt,J�p C Hunsuct'r
CLdCnd Depua P�osn wm�r aa..nr
Approved n to fo m only:
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
PhAip C.Huos k- Dae fete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
ChiefCinl Depu Prosecuting.aao
See reverse for public burden disclosure.
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
a. contract ❑a. bid/offer/application ❑ a. initial filing
b. grant b. initial award b. material change
c. cooperative agreement c. post-award For Material Change Only:
d. loan year quarter
e. loan guarantee date of last report
f. loan insurance
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name
❑Prime ❑Subawardee and Address of Prime:
Tier if known:
Jefferson County
PO Box 563
Port Townsend, WA 98368-
Con ressional District, if known: WA Congressional District, if known:
6. Federal Department/Agency: 7. Federal Program Name/Description:
USDA Rural Developnment
215 Melody Ln
Wenatchee, 98801
CFDA Number, if applicable: 10.766
8. Federal Action Number, if known: 9. Award Amount, if known:
10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if
(if individual, last name, first name, MI): different from No. 10a)
(last name, first name, Ml):
11. Amount of Payment(check all that apply): 13.Type of Payment(check all that apply):
$ ❑actual ❑planned ❑a. retainer
❑b.one-time fee
12. Form of Payment(check all that apply): ❑c.commission
❑a.cash ❑d.contingent fee
❑b.in-kind;specify: nature ❑e.deferred
value ❑f.other;specify:
14. Brief Description of Services Performed or to be Performed and Date(s)of Service, including officer(s),employee(s),or
Member(s)contacted,for Payment Indicated in Item 11:
attach Continuation Sheets SF-LLLA,if necessary)
15. Continuation Sheets SF-LLLA attached: Yes ✓ No
16.Information requested through this form is authorized by title 31 U.S.C.section
1352.This disclosure of lobbying activities is a material representation of fad upon Signature:
which reliance was placed by the her above when this transaction was made or
entered into.This disclosure is required pursuant to 31 U.S.C.1352.This Print Name:Kate Dean
information will be reported to the Congress semi-annually and will be available for
public inspection.Any person who fails to file the required disclosure shall be subject Title: County Commissioner
to a civil penalty of not less that$10,000 and not more than$100,000 for each such
failure. Telephone No.: 3 6 0-3 8 5-915 7 Date:
Authorized for Local Reproduction
Standard Form LLL(Rev.7-97)
Approved by OMB
0348-0046
DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET
ReportmgEntity Jefferson County Page of
Authorized for Local Reproduction
Standard Form-LLL-A