OMB Approval No. 0348-0040
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
As the duly authorized representative of the applicant, I certify that the applicant:
1. Has the legal authority to apply for Federal assistance |
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Act of 1973, as amended (29 U.S.C. §794), which |
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and the institutional, managerial and financial capability |
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prohibits discrimination on the basis of handicaps; (d) |
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(including funds sufficient to pay the non-Federal share |
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the Age Discrimination Act of 1975, as amended (42 |
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of project cost) to ensure proper planning, management |
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U.S.C. §§6101-6107), which prohibits discrimination |
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and completion of the project described in this |
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on the basis of age; (e) the Drug Abuse Office and |
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application. |
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Treatment Act of 1972 (P.L. 92-255), as amended, |
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relating to nondiscrimination on the basis of drug |
2. |
Will give the awarding agency, the Comptroller General |
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abuse; (f) the Comprehensive Alcohol Abuse and |
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of the United States and, if appropriate, the State, |
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Alcoholism Prevention, Treatment and Rehabilitation |
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through any authorized representative, access to and |
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Act of 1970 (P.L. 91-616), as amended, relating to |
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the right to examine all records, books, papers, or |
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nondiscrimination on the basis of alcohol abuse or |
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documents related to the award; and will establish a |
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alcoholism; (g) §§523 and 527 of the Public Health |
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proper accounting system in accordance with generally |
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Service Act of 1912 (42 U.S.C. §§290 dd-3 and 290 ee- |
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accepted accounting standards or agency directives. |
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3), as amended, relating to confidentiality of alcohol |
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and drug abuse patient records; (h) Title VIII of the |
3. |
Will establish safeguards to prohibit employees from |
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Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as |
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using their positions for a purpose that constitutes or |
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amended, relating to nondiscrimination in the sale, |
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presents the appearance of personal or organizational |
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rental or financing of housing; (i) any other |
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conflict of interest, or personal gain. |
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nondiscrimination provisions in the specific statute(s) |
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under which application for Federal assistance is being |
4. |
Will initiate and complete the work within the applicable |
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made; and, (j) the requirements of any other |
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time frame after receipt of approval of the awarding |
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nondiscrimination statute(s) which may apply to the |
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agency. |
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application. |
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5. |
Will comply with the Intergovernmental Personnel Act of |
7. |
Will |
comply, |
or has already complied, with the |
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1970 (42 U.S.C. §§4728-4763) relating to prescribed |
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requirements of Titles II and III of the Uniform |
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standards for merit systems for programs funded under |
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Relocation Assistance and Real Property Acquisition |
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one of the 19 statutes or regulations specified in |
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Policies Act of 1970 (P.L. 91-646) which provide for |
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Appendix A of OPM's Standards for a Merit System of |
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fair and equitable treatment of persons displaced or |
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Personnel Administration (5 C.F.R. 900, Subpart F). |
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whose property is acquired as a result of Federal or |
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federally-assisted programs. These requirements apply |
6. |
Will comply with all Federal statutes relating to |
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to all interests in real property acquired for project |
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nondiscrimination. These include but are not limited to: |
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purposes regardless of Federal participation in |
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(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) |
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purchases. |
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which prohibits discrimination on the basis of race, color |
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or national origin; (b) Title IX of the Education |
8. |
Will |
comply, |
as applicable, with provisions of the |
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Amendments of 1972, as amended (20 U.S.C. §§1681- |
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Hatch Act (5 U.S.C. §§1501-1508 and 7324-7328) |
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1683, and 1685-1686), which prohibits discrimination on |
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which limit the political activities of employees whose |
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the basis of sex; (c) Section 504 of the Rehabilitation |
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principal employment activities are funded in whole or |
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in part with Federal funds. |
Previous Edition Usable |
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Standard Form 424B (Rev. 7-97) |
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Authorized for Local Reproduction |
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Prescribed by OMB Circular A-102 |