LOCAL RECIPIENT ORGANIZATION CERTIFICATION

FORM

(To be retained by Local Board)

As a recipient of Emergency Food and Shelter National Board Program funds made available for Phase 28

and as the duly authorized representative of, I certify that

my public or private organization: (NAME OF LRO)

  • Has the capability to provide emergency food and/or shelter services,
  • Will use funds to supplement and extend existing resources and not to substitute or reimburseongoing programs and services,
  • Is nonprofit or an agency of government,
  • Has an accounting system, and will pay all vendors by LRO check, LRO vendor issued creditcard or LRO debit card,
  • Will conduct an independent annual review/audit if receiving $25,000 or more in EFSP funds,
  • Understands that cash payments (including petty cash) are not eligible under EFSP,
  • Has a Federal Employer Identification Number (FEIN),
  • Practices non-discrimination (LROs with a religious affiliation will not refuse service to anapplicant based on religion, nor engage in religious proselytizing or religious counseling withFederal funds),
  • Has a voluntary board if private, not-for-profit,
  • Will comply with the Phase 28 Responsibilities & Requirements Manual, particularly theEligible and Ineligible Costs section, and will inform appropriate staff or volunteers of EFSPrequirements,
  • Will provide all required reports to the Local Board in a timely manner; (e.g., SecondPayment/Interim and Final Reports),
  • Will expend monies only on eligible costs and keep complete documentation (copies ofcanceled LRO checks -- front and back, invoices, receipts, etc.) on all expenditures for aminimum of three years after end of program,
  • Will spend all funds and close-out the program by my jurisdiction's selected end-of-programdate and return any unused funds to the National Board ($5.00 or more; make checks payableto United Way of America/Emergency Food and Shelter National Board Program),
  • Will provide complete documentation of expenses to the Local Board, if requested, no laterthan one month following my jurisdiction's selected end-of-program date,
  • Will comply with the Office of Management and Budget Circular A-133 if expending $500,000or more in Federal funds,
  • Will comply with lobbying prohibition certification and disclosure of lobbying activities ifreceiving $100,000 or more in EFSP funds, if applicable, and
  • Has no known EFSP compliance exceptions in this or any other jurisdiction.

Signature: ______Print Name:

Title:Date:

LRO ID#: FEIN#:

Address______

City/State/Zip:

Please complete and return this form in order to release funds to your agency.

Anti-Terrorism Compliance Measures

In compliance with the USA PATRIOT Act and other counterterrorism laws, the

United Way of Palm Beach County requires that each agency certify the

following:

“I hereby certify on behalf of that all United Way funds and donations will be used in compliance with all applicable anti-terrorism financing and asset control laws, statutes and executive orders.”

Print Name: Title

Signature:______Date:

Agency Address:

Tax ID:

FISCAL AGENT/FISCAL CONDUIT AGENCY RELATIONSHIP CERTIFICATION FORM

(To be retained by Local Board and Fiscal Agent/Fiscal Conduit)

As a recipient (through the fiscal agent/conduit noted below) of Emergency Food and Shelter National Board Program funds made available for Phase 28 and as the duly authorized representative of

, I certify that my public or private agency:

(NAME OF AGENCY)

  • Has the capability to provide EFSP services,
  • Will use funds to supplement and extend existing resources and not to substitute or reimburse ongoing programs and services,
  • Is nonprofit or an agency of government,
  • Has fiscal agent/fiscal conduit approved by the Local Board:

(Name of Fiscal Agent/Fiscal Conduit),

  • Practices non-discrimination (if an LRO with a religious affiliation, will not refuse service to an applicant based on religion, nor engage in religious proselytizing in any program receiving EFSP funds),
  • Has a Federal Employer Identification Number (FEIN),
  • Has a voluntary board if private, not-for-profit,
  • Will comply with the Phase 28 Responsibilities & Requirements Manual, particularly the Eligible and Ineligible Costs section, and will inform appropriate staff or volunteers of EFSP requirements,
  • Will provide all required information to the Fiscal Agent/Fiscal Conduit,
  • Will incur expenses for eligible program costs and will submit complete documentation on all expenditures to the Fiscal Agent/Fiscal Conduit for payment to the vendors,
  • Will spend all funds and close-out the program by the jurisdiction's selected end-of-program date, and
  • Has no known EFSP compliance exceptions in this or any other jurisdiction.

Signature: ______Print Name:

Title: Date:______

LRO ID#: FEIN#:______

Address ______

City/State/Zip:

CERTIFICATION REGARDING LOBBYING

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

  1. No Federal appropriated funds have been paid or will be paid by or on the 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 any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, contribution, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
  1. If any funds other than Federal appropriated funds have been paid or will be paid 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 this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
  1. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Title 31 U.S.C. §1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

LRO Name LRO ID number

Name/Signature Date

NOTE: Standard Form LLL and instructions are available from the National Board office.