Agenda 11/08/2011 Item #16J4n EXECUTIVE SiJA+II1ZARY
11/8/2011 Item 16.JA
Recommendation to approve a budget amendment recognizing Federal HHS Vote
Program Grant Award 2007 Funds for Voting Accessibility for Individuals with
Disabilities.
OBJECTIVE: To obtain the Board of Commissioner's approval to recognize Federal
HHS Vote Program Grant Award 2007 Funds for Voting Accessibility for Individuals
with Disabilities.
CONSIDERATIONS: The Florida Department of State has been awarded the 2007 U.S.
Department of Health and Human Services (HHS) VOTE Program grant funds in the
amount of $581,812 to assist with making polling places accessible to the disability
community. Supervisor of Elections are eligible to receive a specified amount of this
grant for their respective county based on a formula for distribution. The Florida
Division of Elections shall award the Collier County Supervisor of Elections a total of
$9,845.07, (see Exhibit 1, Attachment A).
FISCAL IMPACT: The Collier County Supervisor of Elections will receive $9,845.07
from the Florida Division of Elections to be appropriated in the Supervisor of Elections
budget with definitive project tracking.
LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney's
Office, does not present a legal issue and only requires a majority vote for Board
approval —SRT.
RECOMMENDATION: That the Collier County Board of County Commissioners
approve a budget amendment recognizing $9,845.07 in Supervisor of Elections grant
fund.
Submitted by: Jennifer. J. Edwards, Supervisor of Elections
Packet Page -1452-
11/8/2011 Item 16.J.4.
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.14.
Item Summary: Recommendation to approve a budget amendment recognizing Federal
HHS Vote Program Grant Award 2007 Funds for Voting Accessibility for Individuals with
Disabilities.
Meeting Date: 11/8/2011
Prepared By
Name: BrockMaryJo
Title: Executive Secretary to County Manager, CMO
10/21/20117:59:59 AM
Submitted by
Title: Executive Secretary to County Manager, CMO
Name: BrockMaryJo
10/21/20118:00:01 AM
Approved By
Name: GreenwaldRandy
Title: Management/Budget Analyst,Office of Management & B
Date: 10/21/20119:39:34 AM
Name: TeachScott
Title: Deputy County Attomey,County Attorney
Date: 10/25/20119:23:46 AM
Name: KlatzkowJeff
Title: County Attorney,
Date: 10/28/2011 1:26:50 PM
Name: SheffieldMichael
Title: Manager- Business Operations, CMO
Date: 10/28/2011 1:56:59 PM
Packet Page -1453-
FLORIDA DEPARTMENT D STATE
RICK SCOTT
Governor
11/8/2011 Item 16.J.4.
KURT S. BROWNING
Secretary of State
MEMO DUM
To: Supervisors of Elections
From: Dr. Gisela Salas, D' ctor, Division of Elections OCT 6 2011 Pm12:17
Date: October 3, 2011
Subject: 2007 HHS VOTE Program Grant
The Department of State has been awarded the 2007 U.S. Department of Health and Human
Services (HHS) VOTE Program grant funds in the amount of $581,812 from HHS to assist with
making polling places accessible to the disability community. Supervisors of Elections are
eligible to receive a specified amount of this grant for their respective county based on a formula
for distribution that includes the number of polling places that were used on Election Day, ^
November 2, 2010. This information was obtained from data provided by the Supervisors of
Elections for the U.S. Election Assistance Commission 2010 Election Administration and Voting
Survey. These funds are available until September 30, 2012.
The Supervisors of Elections may determine which categories to use based on their county's
specific needs. If a county needs to use funds from a category that is normally used for other
purposes, they simply need to write a justification explaining their county's needs regarding
polling place accessibility and why they are using a category that normally would be used for
other purposes.
To request a reimbursement from the HHS grant funds for purchases already made, please use
the attached Certificate for Reimbursement Request for Use of HHS VOTE Program Grant
Funds (DS -DE 130, Revised 7/19/2011). Please submit one of the documents listed below for
each of the items referenced on the Certificate:
• an invoice showing a zero balance; or
an invoice with the check number and date written on it; or
an invoice with a copy of a cancelled check.
A Certificate must be submitted with each request that identifies the purpose and amount of
funding being requested by category. There is no limit on the number of requests that a
supervisor may submit up to the maximum allocated amount for the respective county.
Division of Elections
R. A. Gray Building, Room 316 • 5Pn a -4 -i• u....,..••..s. ctreet • Tallahassee, Florida 32399 -0250
Telephone: (85( Packet Page - 1454 -mile: (850) 245 -6217
election. dos. state. fl.us
11/8/2011 Item 16.J.4.
Supervisors of Elections
,--� 2007 HHS VOTE Program Grant
October 3, 2011
Page Two
Please sign and date the enclosed Memorandum of Agreement and the Debarment and
Suspension form and return them to the Division of Elections. You will be provided with a copy
of the agreement upon execution by the Division. When your county is ready to apply for a
reimbursement, please submit the Certificate for Reimbursement Request for Use of HHS Vote
Program Grant Funds as described above.
If you have any questions or would like additional information, please contact Althera Johnson at
(850) 245 -6211 or Joyce Durbin at (850) 245 -6206.
GS /jd/ma
Enclosures
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11/8/2011 Item 16.J.4.
MEMORANDUM OF AGREEMENT
FOR FEDERAL HHS VOTE PROGRAM GRANT
This agreement, effective as of the date fully executed by the State of Florida,
Department of State, Division of Elections ( "Department "), an agency of the State of Florida, the
address of which is the R.A. Gray Building, Room 316, 500 South Bronough Street, Tallahassee,
FL 32399 -0250 and Collier County Supervisor of Elections, The Honorable Jennifer J. Edwards
( "Recipient "), the address of which is 3295 Tamiami Trail East, Reverend Dr. MLK, Jr. Building,
Naples, FL 34112 -5758, is for the purpose of governing the receipt and use of federal funds as
specified herein.
I. Governing Law
Grant funds are made available pursuant to Title II, Part 5, Subtitle D, section 261 of the
Help America Vote Act of 2002 (HAVA) (42 USC 15421) to satisfy the accessibility requirements
for individuals with disabilities. The Voting Access for Individuals with Disabilities (VOTE)
Program within the Department of Health and Human Services (HHS) administers these grants
to the States for this purpose.
11. Disbursement
I
Through the Grants and Donations Trust Fund, the Department of State is authorized to
distribute to all 67 county Supervisors of Elections a sum total of five hundred eighty -one
thousand eight hundred twelve dollars ($581,812) in federal HHS Vote Program Funds. The
amount allocated for each respective county is set forth in Exhibit 1 to Attachment A. These
funds, if unused, will revert to the federal program by the end of September 30, 2012.
III. Scope of Use /Restrictions
The funds shall be used solely to reimburse expenses made to establish, expand, and
improve access to and participation in the election process by individuals with disabilities in the
four categories of accessibility specified in Attachment A, incorporated by reference.
No Recipient shall receive funds pursuant to this Agreement until the Recipient submits
to the Department the two certificates specified in Attachment A. No Recipient shall use any
funds received hereunder to support lobbying activities to influence proposed or pending
federal or state legislation or appropriations but this does not affect the right of the Recipient,
or that of any other organization to petition Congress, or any other level of Government,
through the use of other resources.
IV. Monitoring, Audits, and Reporting
The administration of resources awarded to the Recipient may be subject to monitoring,
audits and reporting requirements herein.
MOA #2011 - 2012 -0002 Page 1 of 4
Packet Page -1456-
11/8/2011 Item 16.J.4.
A. Monitoring
In addition to reviews of audits conducted in accordance with OMB Circular A -133, as revised,
and Section 215.97, F.S., (see Part B "Audits ") monitoring procedures may include, but not be
limited to, on -site visits by Department staff, limited scope audits as defined by OMB Circular A-
133, as revised, and /or other procedures. By entering into this agreement, the Recipient agrees
to comply and cooperate with any monitoring procedures /processes the Department deems
appropriate.
B. Audits
1. Federally Funded Audits (OMB Circular A -133, as revised.)
In the event that the Recipient expends $500,000 or more in Federal awards in its fiscal
year, the recipient is required to have a single or program - specific audit conducted in
accordance with the provisions of OMB Circular A -133, as revised. Attachment A and
Exhibit -1 indicate Federal resources awarded through the Department by this
Agreement. In determining the Federal awards expended in its fiscal year, the Recipient
shall consider all sources of Federal awards, including Federal resources received from
the Department. The determination of amounts of Federal awards expended should be
in accordance with the guidelines established by OMB Circular A -1331 as revised. An
audit conducted by the Auditor General must satisfy the requirements of Subpart E of
OMB Circular.A -133, as revised.
In connection with the audit requirements the Recipient shall fulfill the responsibilities
of an auditee as provided in Subpart C of OMB Circular A -133, as revised.
If the Recipient expends less than $500,000 in Federal awards in its fiscal year, an audit
conducted in accordance with the provisions of OMB Circular A -133, as revised, is not
required. The Recipient, however, must make records available for review or audit upon
request by appropriate officials of HHS, the Department, and the General Accounting
Office (GAO). If the Recipient elects to have an audit conducted in accordance with the
provisions of OMB Circular A -133, as revised, the cost of the audit must be paid from
non - federal resources (i.e., resources obtained from other than Federal entities).
2. Other audits
The Department may conduct a limited scope audit of federal funds as defined by OMB Circular
A -133 (as revised) or other financial analysis or review of federal funds as permitted by federal
law. In the event the Department determines that a limited scope audit or other type of audit
of the Recipient is appropriate, the Recipient agrees to comply with any additional instructions
provided by Department staff to the Recipient regarding such audit. If the Department
determines that federal funds received under this Agreement were used for any unauthorized
purpose or that the Recipient did not comply with this agreement or state or federal
requirements for receipt, expenditure, or accounting, the Recipient must return or repay these
federal funds in an amount sufficient to ensure or obtain compliance, including expenses for any
corrective or remedial action.
MOA #2011 - 2012 -0002 Page 2 of 4
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11/8/2011 Item 16.J.4.
The Recipient further agrees to comply and cooperate with any inspections, reviews,
investigations, or audits deemed necessary by the Department of State, Chief Financial Officer
(CFO) or Auditor General.
Additional guidance to state and federal monitoring and auditing requirements may be found at
http://www.eac.gov, and http:// election. dos .state.fl.us /hava/index.shtml
C. Reporting
Copies of financial reporting packages as described in section .320(c), OMB A -133 (as revised)
for audits conducted by or on behalf of the Recipient pursuant to Section IV.6.1 of this
agreement, shall be submitted as required by sections .320(d) of such circular to:
Department of State
Division of Elections
R.A. Gray Building, Ste 316
500 S. Bronough St.
Tallahassee, FL
32399 -0250
Department of State
Office of Inspector General
R.A. Gray Building, Rm. 114A
500 S. Bronough Street
Tallahassee, FL
32399 -0250
Auditor General's Office
Room 401, Pepper Bldg
111 West Madison St.
Tallahassee, FL
32399 -1450
Federal Audit
Clearinghouse
Bureau of the Census
1201 East 10`h St.
Jeffersonville, IN
47131
Other Federal agencies and pass- through entities in accordance with Sections .320 (e) and (f),
OMB Circular A -133 (as revised).
Any reports, management letter, or other information required to be submitted to the
Department pursuant to this agreement shall be submitted timely and in accordance with OMB
Circular A -133, the Florida Statutes, and Chapter 10.550 (local governmental entities) of the
Rules of the Auditor General, whichever is applicable
( http: / /www.myflorida.com /audgen /pages /localgovt.htm). The correspondence accompanying
the financial reporting package forwarded to the Department must include the date the
Recipient received the reporting package.
V. Record Retention
The Recipient shall keep and maintain accurate and detailed records sufficient to
demonstrate its compliance with the terms of this agreement. The Recipient shall retain these
records for five fiscal years in accordance with the guidelines of the Department of Financial
Services and the Office of the Auditor General, or three years after the date an audit report is
issued, whichever is later, and the Recipient shall allow the Department or its designee, CFO, or
Auditor General access to such records, including access to the audit working papers upon
request.
VI. Entirety of the Agreement
All terms and conditions of this agreement are fully set forth in this
document and its attachments and shall be governed by the laws of the State of Florida
regardless of any conflict of laws provisions. In any proceeding or action brought under this
section, the parties agree that the prevailing party will be entitled to its reasonable attorney's
fees from the other party. The parties agree that proper venue will be in Leon County, Florida.
MOA #2011 - 2012 -0002 Page 3 of 4
Packet Page -1458-
11/8/2011 Item 16.J.4.
IN WITNESS THEREOF, the parties have caused this Agreement to be executed by their
undersigned officials as duly authorized.
County Supervisor of Elections/
Recipient
By:
.'510
Typed name and title
fitness
i(7I�1�
Date
Department of State, Division of Elections/
Department
By:
Typed name and title
Witness
Date
Please complete, sign & return the Memorandum of. Agreement and
Certification Regarding Debarment and Suspension to:
Joyce Durbin, HAVA Funds :Coordinator, Florida Department of State,
Division of Elections, R.A. Gray Building, Room 316, 500 South Bronough Street,
Tallahassee, Florida 32399 -0250
MOA #2011 - 2012 -0002 Page 4 of 4
Packet Page -1459-
11/8/2011 Item 16.J.4.
ATTACHMENT A to MOA # 2011 - 2012 -0002
FEDERAL RESOURCES AWARDED TO THE RECIPIENT UNDER THIS AGREEMENT CONSIST OF THE FOLLOWING:
Federal Program: U.S. Department of Health & Human Services- CFDA 93.617, Voting
Access for Individuals with Disabilities — (i.e. VOTE Program) for the amount specified in
Exhibit 1 to Attachment A.
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED UNDER THIS AGREEMENT
ARE AS FOLLOWS:
1. The Recipient may only use the funds received pursuant to this Agreement for expenses in
any one or more of the following categories of accessibility:
• Category 1: Making polling places accessible to individuals with disabilities (this includes
the path of travel, entrances, exits, and voting areas of each polling facility);
• Category 2: Providing access and participation to individuals with disabilities (this
means providing the same opportunities for access and participation, privacy and
independence provided to all other voters);
• Category 3: Training election officials, poll workers, and election volunteers on how best
to promote the access and participation of individuals with disabilities in elections for
Federal office; and n
• Category 4: Providing individuals with disabilities with information on accessibility of
polling places.
The Recipient determines which categories to use based on the respective county's specific
needs. If the Recipient chooses to use funds for an item that is normally covered by another
category, written justification explaining the reason must be provided.
2. Before receiving these funds, the Recipient must complete and submit to the Department:
a. Certificate for Request of HHS Program Grant Funds (DS -DE 130, Revised 7/19/2011)
attached as Exhibit -2. Supporting documents of expenditures must be included with the
Certificate. Examples of acceptable documentation include copies of invoices or proof of
payment (e.g., copy of cancelled check or check number and date paid written on the
invoice or receipt paid by a bank card and a copy of the bankcard statement on the bank's
letterhead.
b. Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion
Lower Tier Covered Transactions (ED Form GCAS -009 (6 /88)(attached as Exhibit -3).
Executive Order 12549, Debarment and Suspension, 45 CFR 1183.35, prohibits the
disbursement of federal funds to the intended recipient or any sub - recipient of such funds
unless such recipient and each sub - recipient, if any, certify that they are not excluded or
disqualified from receiving federal funds by any federal department or agency.
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11/8/2011 Item 16.J.4.
STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT CONSIST OF THE FOLLOWING:
N/A
MATCHING RESOURCES FOR FEDERAL PROGRAMS: N/A
SUBJECT TO SECTION 215.97, FLORIDA STATUTES: N/A
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS AGREEMENT AR
AS FOLLOWS; N/A
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11/8/2011 Item 16.J.4.
EXHIBIT -1, ATTACHMENT A
to MOA #2011- 2012 -0002 10-\
DEPARTMENT OF STATE
DIVISION OF ELECTIONS
POLLING PLACE ACCESSIBILITY - HHS GRANTS
FY 2007 Grant
COUNTY
POLLING
PLACES
ELECTION DAY
NOV. 2, 2010
TOTAL
DISTRIBUTION
PER COUNTY
MAKING POLLING
PLACES
ACCESSIBLE
TO INDIVIDUALS
WITH
DISABILITIES
5%
PROVIDING
ACCESS AND
PARTICIPATION
TO INDIVIDUALS
WITH
DISABILITIES
90%
TRAINING
ELECTION
OFFICIALS,
POLL WORKERS
& ELECTION
VOLUNTEERS
3%
PROVIDING
INFORMATION
ON
POLLING
PLACE
ACCESSIBILITY
2%
Alachua
70
7,410.27
370.51
6,669.24
222.31
148.21
Baker
8
846.89
42.34
762.20
25.41
16.94
Bay
53
5,610.63
280.53
5,049.57
168.32
112.21
Bradford
15
1,587.91
79.40
1,429.12
47.64
31.76
Brevard
127
13 444.35
672.22
12 099.91
403.33
268.89
Broward
782
82 783.29
4,139.16
74,504.96
2,483.50
1,655.67
Calhoun
12
1270.33
63.52
1,143.30
38.11
25.41
Charlotte
37
3,916.86
195.84
3,525.17
117.51
78.34
Citrus
43
4,552.02
227.60
4,096.82
136.56
91.04
Clay
60
6,3 1.66
317.58
5,716.49
190.55
127.03
Collier
93
9,845.07
492.25
8,860.56
295.35
196.90
Columbia
22
2 328.94
116.45
2,096.05
69.87
46.58
Desoto
13
1376.19
68.81
1,238.57
41.29
27.52
Dixie
10
1,058.61
52.93
952.75
31.76
21.17
Duval
250
26,465.25
1323.26
23,818.72
793.96
529.30
Escambia
83
8,786.46
439.32
7,907.82
263.59
175.73
Fla ler
35
3,705.13
185.26
3,334.62
111.15
74.10
Franklin
8
846.89
42.34
762.20
25.41
16.94
Gadsden
25
2,646.52
132.33
2,381.87
79.40
52.93
Gilchrist
10
1058.61
52.93
952.75
31.76
21.17
Glades
10
1,058.61
52.93
952.75
31.76
21.17
Gulf
9
952.75
47.64
857.47
28.58
19.05
Hamilton
9
952.75
47.64
857.47
28.58
19.05
Hardee
12
1,270.33
63.52
1,143.30
38.11
25.41
Hendry
22
2,328.94
116.45
2,096.05
69.87
46.58
Hernando
47
4,975.47
248.77
4,477.92
149.26
99.51
Highlands
25
2,646.52
132.33
2,381.87
79.40
52.93
Hillsborough
292
30,911.41
1,545.57
27 820.27
927.34
618.23
Holmes
7
741.03
37.05
666.92
22.23
14.82
Indian River
35
3,705.13
185.26
3,334.62
111.15
74.10
Jackson
14
1,482.05
74.10
1,333.85
44.46
29.64
Jefferson
15
1,587.91
79.40
1,429.12
47.64
31.76
Lafayette
5
529.30
26.47
476.37
15.88
10.59
Lake
95
10,056.79
502.84
9,051.11
301.70
201.14
Lee
136
14,397.09
719.85
12,957.39
431.91
287.94
Leon
104
11,009.54
550.48
9,908.59
330.29
220.19
Levy
15
1,587.91
79.40
1,429.12
47.64
31.76
Liberty
7
741.03
37.05
666.92
22.23
14.82
Madison
11
1,164.47
58.22
1,048.02
34.93
23.29
Manatee
127
13 444.35
672.22
12,099.91
403.33
268.89
Marion
122
12,915.04
645.75
11,623.54
387.45
258.30
Martin
46
4,869.61
243.48
4,382.64
146.09
97.39
Miami -Dade
541
57,270.80
2,863.54
51,543.72
1,718.12
1,145.42
Monroe
36
3,811.00
190.55
3,429.90
114.33
76.22
Nassau
18
1905.50
95.27
1714.95
57.16
38.11
Okaloosa
52
51504.77
275.24
4,954.29
165.14
110.10
Okeechobee
16
1,693.78
84.69
1,524.40
50.81
33.88
10rancie
220
23,289.42
1,164.47
20,960.48
698.68
465.79
Osceola
50
5,293.05
264.65
476374
158.79
105.86
Palm Beach
451
47,743.31
2,387.17
42,968.98
1,432.30
954.87
Exhibit 1 to Attach A - -HHS Distribution 2007 Funds FINAL Packet Page -1462- July 23, 2010
110\
11/8/2011 Item 16.JA
EXHIBIT -1, ATTACHMENT A
to MOA #2011 - 2012 -0002
DEPARTMENT OF STATE
DIVISION OF ELECTIONS
POLLING PLACE ACCESSIBILITY - HHS GRANTS
FY 2007 Grant
5% - Making polling places accessible to individuals with disabilities (this includes the path of travel, entrances,
exits, and voting areas of each polling facility)
90% - Providing access and participation to individuals with disabilities (providing the same opportunities
for access and participation, privacy and independence provided to all other voters)
3% - Training election officials, poiiworkers, and election volunteers on how best to promote the access and
participation of individuals with disabilities in elections for Federal office.
2% - Providing individuals with disabilities with information on accessibility of polling places
Exhibit 1 to Attach A - -HHS Distribution 2007 Funds FINAL Packet Page -1463-
July 23, 2010
MAKING POLLING
PROVIDING
TRAINING
PROVIDING
POLLING
TOTAL
PLACES
ACCESS AND
ELECTION
INFORMATION
PLACES
DISTRIBUTION
ACCESSIBLE
PARTICIPATION
OFFICIALS,
ON
ELECTION DAY
PER COUNTY
TO INDIVIDUALS
TO INDIVIDUALS
POLL WORKERS
POLLING
NOV. 2, 2010
WITH
WITH
& ELECTION
PLACE
DISABILITIES
DISABILITIES
VOLUNTEERS
ACCESSIBILITY
COUNTY
5%
90%
3%
2%
Pasco
129
13, 656.07
682.80
12,290.46
409.68
273.12.
Pinellas
251
26, 571.11
1,328.56
23 914.00
797.13
531.42
Polk
154
16,302.59
815.13
14,672.33
489.08
326.05
Putnam
34
3,599.27
179.96
3,239.35
107.98
71.99
St. Johns
44
4657.88
232.89
4,192.10
139.74
93.16
St. Lucie
54
5,716.49
285.82
5,144.84
171.49
114.33
Santa Rosa
35
3 705.13
185.26
3,334.62
111.15
74.10
Sarasota
124
13, 26.76
656.34
11814.09
393.80
262.54
Seminole
98
10,374.38
518.72
9,336.94
311.23
207.49
Sumter
35
3,705.13
185.26
3 ,334.62
111.15
74.10
Suwannee
16
1,693.78
84.69
1,524.40
50.81
33.88
Taylor
14
1 482.05
74.10
1,333.85
44.46
29.64
Union
6
635.17
31.76
571.65
19.05
12.70
Volusia
136
14 397.09
719.85
12,957.39
431.91
287.94
Wakuila
12
1,270.33
63.52
1,143.30
38.11
25.41
Iton
33
3493.41
174.67
3,144.07
104.80
69.87
hin ton
16
1,693.78
84.69
1,524.40
50.81
33.88
1TOTAL
5,4961
581,812.00 1 29,090.601 523,630.80 r 17,454.36 11,636.24
5% - Making polling places accessible to individuals with disabilities (this includes the path of travel, entrances,
exits, and voting areas of each polling facility)
90% - Providing access and participation to individuals with disabilities (providing the same opportunities
for access and participation, privacy and independence provided to all other voters)
3% - Training election officials, poiiworkers, and election volunteers on how best to promote the access and
participation of individuals with disabilities in elections for Federal office.
2% - Providing individuals with disabilities with information on accessibility of polling places
Exhibit 1 to Attach A - -HHS Distribution 2007 Funds FINAL Packet Page -1463-
July 23, 2010
11/8/2011 Item 16.J.4.
Exhibit -2 to Attachment A of MOA #2011 - 2012 -0002
CERTIFICATE FOR REIMBURSEMENT REQUEST FOR USE 110�
OF HHS VOTE PROGRAM GRANT FUNDS
I, County Supervisor of
Elections, request funds from the Voting Access for Individuals with Disabilities (VOTE) Program
within the Department of Health and Human Services (HHS) to reimburse expenditures as
follows:
Request for Funds
Category 1 To make polling places accessible to individuals with disabilities (this includes the
path of travel, entrances, exits, and voting areas of each polling facility)
$ Amount of request
Category 2 To provide access and participation to individuals with disabilities (this means
providing the same opportunities for access and participation, privacy and independence
provided to all other voters)
$ Amount of request
Category 3 To train election officials, poll workers, and election volunteers on how best to
promote the access and participation of individuals with disabilities in elections for Federal
office
$ Amount of request
Category 4 : To provide individuals with disabilities with information on accessibility of polling
places
$ Amount of request
$ Total amount of funds requested above.
(Attach supporting documentation of expenditures made in the respective categories of
activities, written justification when needed and the specified polling place where expenditures
were made, if applicable.]
Use of Funds
I hereby certify that the funds:
• Will be used solely to reimburse expenses made in accordance with the requirements of
the HHS VOTE Program grant award and this agreement;
• Will not be used to reimburse expenses for the support of state or federal lobbying
activities in influencing proposed or pending federal or state legislation or
appropriations;
Supervisor of Elections Date
DS -DE 130
Revised 7/19/2011
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11/8/2011 Item 16.J.4.
Exhibit 3 to Attachment A of MOA #2011- 2012 -0002
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12549, Debarment
and Suspension, 45 CFR 1183.3 5, Participants' responsibilities. The regulations were published as
Part VII of the May 26, 1988 Federal Register (pages 19160 - 19211). Copies of the regulations may be
obtained by contacting the person to which this proposal is submitted.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it
nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any federal department or agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this
certification, such prospective participant shall attach an explanation to this proposal.
Name and Title of Authorized Representative
ED Form GCS -009, 6/88
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16, 19t
11/8/2011 Item 16.JA
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set
out below.
2. The certification in this clause is a material representation of fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly
rendered an erroneous certification, in addition to other remedies available to the federal government, the
department or agency with which this transaction originated may pursue available remedies, including
suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the person to which this
proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as
used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in
obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower'tier covered transaction with a person
who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this proposal that it will include the clause
titled "Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion -Lower Tier
Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for
lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List (Telephone Number).
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order
to render in good faith the certification required by this clause. The knowledge and information of a
participant is not required to exceed that which is normally possessed by a prudent person in the ordinary
course of business dealings.
9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntary excluded from participation in this transaction, in addition to other remedies available
to the federal government, the department or agency with which this transaction originated may pursue
available remedies, including suspension and/or debarment.
ED Form GCS -009, 6/88
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