008-03
pc",+- IT_
-
DESIGNATION OF APPLICANTS AGENT
RESOLUTION
BE IT RESOLVED BY OF THE BOARD OF SUPERVISOR$)F
(Governing Body)
FREDERICK COUNTY, VA
(Public Entity)
THAT
GARY A. DUBRUELER
DIRECTOR
(Name of Incumbent)
(Official Position)
Is hereby authorized to execute for and in behalf of
Frederick County, Virginia
, a public entity established under the laws of the State of Virginia,
this application and to file it in the appropriate State Office for the purpose of obtaining certain Federal financial assistance
under the OIP, National Domestic Preparedness Office Grant Prograrn(s), administered by the Commonwealth of Virginia.
Frederick County Virginia . - .
That, ' a public entity established under the laws of the
Commonwealth of Virginia, hereby authorizes its agent to provide to the Commonwealth and to the Office of Justice
Programs (OIP) for all matters pertaining to such Federal financial assistance any and all information pertaining to these
Grants as may be requested. .
Passed and approved this
13th
day of
August
,20
03
Richard C. Shickle, Chairman, Board of Supervisors
\L-\LQ
. (Name and Tile)
~LU.J . c.\.~~
v
(Name and Tile)
(Name and Tile)
CERTIFICATION
I,
John R. Riley, Jr.
, duly appointed and
County Administrator
(Title)
of
(name)
Frederick County, Virginia
(entity)
, do hereby certify that the above is a true and correct copy of a
Resolution passed and approved by the Board of SupervisoBf3
(Goveming Body)
Frederick County, VA
(Public Entity)
13th
Day of
August
03
20-
~~~.
(sign e)
On the
Date:
August 14, 2003
County Administrator
(Onici.! Position)
Board of Supervisors Resolution No.: 008~03
VDEM ,OJP GRANT DAA. REV 2,07117/2003
COUNTY OF FREDERICK, VIRGINIA
FIRE AND RESCUE DEPARTMENT
107 North Kent Street
Winchester, VA 22601
MEMORANDUM
TO:
Board of Supervisors j%
Gary A. DuBrueler, Director
Fire and Rescue Departmen
Dennis D. Linaburg
Fire Marshal
Gary A. DuBrue1er
. Director
SUBJECT:
2003-11, Office of Domestic Preparedness
State Homeland Security Grant Program
t
RECEIVED
JUL 2003
Frederick County
Adminif Office
By ,,'
...~\.:."'}t
FROM:
;:U TE:
July 29, 2003
Tht: Vilginia Department of Emergency Management has announced the allocation of the 2003-
n, Office of Domestic Preparedness State Homeland Security Grant Program. This grant
program is designed to allow local governments in Virginia to supplement funding recd ved from
the 2003-} Equipment Grant Program. This grant is for first responders to have better
preparedness to combat and deal with terrorist acts involving weapons of mass destruction and to
miiigate the costs of enhanced security at critical infrastructure facilities during periods of
ho~ti]ities. Therefore, Frederick County, Virginia has been allocated a total of $1 72,525 under
(his grant.
Each jurisdiction must complete application and required federal and state documents for the
grant in order to receive funding. The application contains a Designation of Applicants Agent
for the grant process through which the grants must flow. Attached is a Designation of
Applicants Agent Resolution that requires the approval of the Board of Supervisors to appoint
myself, Gary A. DuBrueler, as the Designated Agent for Frederick County, Virginia. This
resolution signed by the Chairman of the Board of Supervisors is required. Upon receipt of the
grant application and the signed Resolution, VDEM will transfer the total amount to the County
of Frederick. It is the responsibility of the jurisdiction to determine what equipment wiJI be
purchased and to ensure that only eligible equipment is procured.
If you have any questions or concerns in regard to the grant application 01' the attached
resolution, please do not hesitate to contact me.
GAD:j1c
Attachment: as stated
Cc: 2003 Office of Domestic Preparedness
Equipment Program Grant
(up -tu C\l'rtYD1 2:>h.tr\-e(
II ') D; \ \ C..1( f\('\'3+ ~ \\LI\1.)01'~
Director (540) 665-5618
.
Fire Marshal (540) 665-6350
.
Fax (540) 678-4739
VIRGINIA DEPARTMENT OF EMERGENCY MANAGEMENT
DOMESTIC PREPAREDNESS PROGRAM
GRANT APPLICATION
Virginia Department of Emergency Management
10501 Trade Court
Richmond, VA 23236
804-897-6500
Grant Fundin Year
2003 - II
ruRISDICTION/ AGENCY
Frederick Count
inia
ADDRESS
107 North Kent Street
Winchester, Virginia 22601
FAX #
540-667-0370
DESIGNATED AGENT
NAME
Mr. Gary A. DuBrueler, Director
ADDRESS
107 North Kent Street, Suite 106
Winchester, Virginia 22601
540-665-5618
FAX #
540-678-4739
GRANT IS TO BE USED FOR: POLICE 0
FIRE f]
HAZMAT 0
EM. MED. )(2J
GRANT IS FOR MUL TI-ruRISTICTIONAL USE: YES 0 NO U
IF YES FILL OUT ATTACHMENT A FOR EACH JURISDICTION PARTICIPATING IN PROPOSAL
OJP GRANT APPLICATION. REV 1.07/1712003
Equipment Coordination Certification
I certify that:
Use of these funds to meet irrunediate equipment replacement needs and address critical
ongoing equipment needs will be coordinated with other ongoing Federal disaster
recovery initiatives related to the September 11, 2001, terrorist attack on the World Trade
Center and with the State's domestic preparedness strategy.
Designated Agent of
Frederick County, Virginia
Locality
Gary A. DuBrueler
Name
Director
Tiele
LEVEL OF TRAINING AND EQUIPMENT
PURCHASE AND USE
I certify that:
Use of these grant funds to purchase any of the equipment authorized by this grant is
done so with the express knowledge that there are levels of "training certification" that
may be required by Federal and State laws, rules and regulations to use such equipment.
To allow response personnel to have and use this equipment is done so by this
Jurisdiction having been informed of these restrictions and in no way is the
Commonwealth of Virginia and the Department of Domestic Preparedness, DOJ
responsible for any consequence oftrus use.
For any equipment that this Jurisdiction may purchase under this grant and it is
determined that our personnel require additional training and/or "certification" this
training and lor "certification' will be obtained prior to use of the equipment at issue.
Designated Agent of
Frederick County, Virginia
Locality
Gary A. DuBrueler
Name
Director
Tille
VDEM - OJP GRANT LEVEL OF TRAINING, REV I. 11/1 &12002
APPLICATION FOR
OM B Approval No 0348
FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Idenofier
Aunust 14 2003
11. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE State Application Identifier
Application Pre application
@constructlon 8 Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier
X Non-Construction Non-Construction
5. APPLICANT INFORMATION
Legal Name: Organizational Unit:
. . ~L- ....~, ,......." vi,......~...~= Fire and Rescue
Address (give city. county. State, and zip code): Name and telephone number ot person to be contacted on matters involving
107 North Kent Street this application (give area code)
Winchester, Virginia 22601 Gary A. OuBrueler, Director
54-0-665 5618
6. EMPLOYER IDENTIFICATION NUMBE~IN): 7. TYPE qF APPLICANT: (enter appropriate Jetter in box)
[511] -~ 0
A. State H. Independent School Dis!.
8. TYPE OF APPLICATION: B. County I. State Controlled Institution of Higher Leamin\;
ONew OContinuatlon 'ORBYISIOn C. Municipal J. Private University
D. Township K. Indian Tribe
If Revision. enter appropriate letter(s) in box(es) 0 0 E. InterSfate L. Individual
F.lntermunicipal M. Profit Organization
A. Increase Award B. Decrease Award C. Increase Duration G. Special District N. Other (Spec'''''
D. Decrease Duration Other (specify): -..
9. NAME OF FEDERAL AGENCY:
FederallOmergency Management Agency
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
OJ - [IT]
TITLE '.
.1.. AREAS AFFECTED BY PROJECT(Cities, Counties, States. etc.):
13. PROPOSED PROJECT: 14. CONGRESSIONAL DISTRICTS OF: ~ ..~
Start Date I Ending Date a. Applicant b. Projecf
15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER: 12372 PROCESS?
a. Federal $ .00
a. YES. THIS PREAPPLlCATION/APPLlCATiON WAS MADE AVAILABLE
b. Applicant $ .00 TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR
REVIEW ON:
c. State $ 00
.
DATE
d. Local $ .00 .
b. No. 8PROGRAM IS NOT COVERED BY E.O. 12372
e. Other $ 00 . OR PROGRAM HAS NOT BEEN SELECTED BY STATE
'- FOR REVIEW
f. Program Income $ 00 '.
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
g. TOTAL $ .00 DYes If "Yes," attach an explanation. ONO
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLlCATlON/PREAPPLlCATlON ARE TRUE AND CORRECT, THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
,ACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Ty~e Name of Authorized Representative
c. Telephone Number
540-665-561
e. Date Signed
8/14/03
Standard Form 424 (Rev. 7.97)
Prescribed t:ty OMS Cin:ular A-1 02
PrevIous EdItion Usable
Aultlorl::ed for Local Reproduction
Instructions for Completion of the Application for Federal Assistance (SF- 424)
The Application for Federal Assistance is a standard form used by most Federal agencies. This form contains 18 different items,
which arc to bc completed before submission. All applications should include a completed and signed SF- 424.
-
Item Instructions
1 Type of Submission: If this proposal is not for construction or building purposes, check "Non-Construction."
2 Date Submitted: Indicate the date you sent the application to OJP. The "Application Identifier" is the number
assigned by your jurisdiction, if any. If your jurisdiction does not assign an identifier number, leave this space blank.
3 Date Received by State: Leave blank. This block is completed by the State single point of contact, if applicable.
4 Date Received by Federal Agency: This item will be completed by OJP.
5 Applicant Information: The "Legal Name" is the unit of government ofth,: parent organization. For example,
the primary or parcnt organization ofa law enforcement agency is the name of the city or township. Thus the city or
township should be entered into the Legal Name box and the name of the law enforcement agency would be entered into
the Organizational Unit box. Designate one person as the contact, and include their telephone number.
6 Employer Identification Number: Each employer receives an employer identification number from the Internal
Revenue Service. Generally, this number can be easily obtained from your agency's accountant or comptroller.
7 Type of Applicant: Enter the appropriate letter in this space. If the applicant is representing a consortium of
agencies, specify by checking Block N and entering "consortium".
8 Type of Application: Check either "new" or "continuation." Check new if this will be your first award for this
purpose described in the application, even if the applicant has received prior awards for other purposes. Check
"continuation", if the project will continue activities ofa project, that was begun under a prior award.
9 Name of Federal Agency: Type in the name of the awarding agency, such as "Office of Juvenile Justice and
Delinquency Prevention."
10 Catalog of Federal Domestic Assistance Number: This would be contained inthe program announcement.
11 Descriptive Title of Applicants Project: Type in the: (I) title of the program as it appears in the solicitation
or announcement; (2) name ofthe cognizant Federal agency, ex. U.S. Department of Education; and (3) applicant's
fiscal year, i.e. twelve month audit period, ex: 1O/l/98-9/30/99.
12 Areas Affected by Project: Identify the geographic areal s) of the project. Indicate "Statewide" or "National", if
applicable.
13 Proposed Project Dates: Fill in the proposed begin and end dates of the project.
14 Congressional Districts: Fill in the Congressional Districts in which the project will.be located as
well as the Congressional District(s) the project will serve. Indicate "Statewide" or "National," ifappiicable.
15 Estimated Funding: In line "a," enter the Federal funds requested, not to exceed the dollar amount allocated in
the program announcement. Indicate any other resources that wi II available to the project and the source of those funds
on lines "b-f," as appropriate.
16 State Executive Order 12372: Some states require you to submit your application to a State "Single Point of
Contact" (SPOC) to coordinate applications for Federal funds. If your State requires a copy of your application, indicate
the date submitted. Ifa copy is not required, indicate the reason. (Refer to the "Administrative Requirements" section
of the program announcement, for more information.) The SPOC is not responsible for forwarding your application.
17 Delinquent Federal Debt: This question applies to the applicant organization. Categories of debt include
delinquent audit allowances, loans, and taxes.
18 Authorized Representative: Type the name of the person legally authorized to enter into agreements on behalf of
your agency. This signature on the original application must be signed in blue ink and/or stamped as "original" to help
identify the original.
Roy. sm
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
Approved by OMS
0:>48-0048
'See reverse for Dublic burden disclosure.)
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
I~ a. contract Da. bid/offer/application o 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
o Prime o Subawardee and Address of Prime:
Tier ---' if known:
Congressional District, if known: Congressional District, if known:
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number, if applicable: _________
8. Federal Action Number, if known: 9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
(if individual, last name, first name, MI): different from No. 10a)
(last name, first name, M/):
NONE DONE N/A
11 Information reQuested througl"l this larm IS authorized by hUt 31 u.s:C. secllon Signature:
. 1352. ThIS disclosure 01 lobbYing aCUVlhes IS a melenal representahon of fact
upon which reliance was placed by the tier above when Ims transac\iQrl was maO. Print Name: Garv A. OuBrueler
or entered "110. This disclosure is reQuired pursuant to 31 U S.C. 1352. This
,nformalion will be reported 10 the Congress semi-annually and will be available fOf Title: Director
public rnspec1lon. Any person who fails 10 file the reQuired disclosure sMU be
subject 10 I crV1l penalty 01 nol less Ihat $10,000 and not more than $100.000 lor Telephone No.: 540-56~5-5618 Date: 8/14/03
eaCh such !allure.
Federal Use Only: I Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be compieted by the reporting entity. whether subawardee or prime Federal recipient. at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S,C, section 1352, The filing of a form is required for each payment or agreemenl10 make
payment to any iobbying entity for influencing or attempting to influence an officer or empioyeeof any agency, a Member of Congress, an officer or employee of
Congress, or an employeeof a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and material
change report, Refer to the implementing guidance published by the Office of Management and Budget for additional information,
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of e covered Federal action.
2. Identify the status of the covered Federal action.
:>. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name. address, city, State and zip code of the reporting entity. include Congressional District. if known. Check the appropriate classification
of the reporting entity that designates ~ it is. or expects to be. a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee
of the prime is the 1 sttier, Subawards include but are nollimited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in 1lem 4 checks "Subawardee: then enter the full name, address, city. State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6, Enter the nameof the Federal agency making the award or loan commitment. Include at least one organizationallevei below agency name, if known. For
exampie, Department of Transportat"'". United States Coast Guard.
7. Enter the Federai program name or ~cription for the covered Fe.deral action (item 1). If known. enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments,
8, Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g.. Request for Proposal (RFP) number;
InVItation for Bid (IFB) number; grant announcement number; the contract. grant, or loan award number; the appiication/proposal control number
assigned by the Federal agency). Include prefixes, e,g.. "RFP-DE-90-001 ,.
9, For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity Identified in item 4 or 5.
10. (a) Enter the full name, address. city, State and zip code of the lobbying regIstrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services. and include full address if different from 10 (a). Enter Last Name, First Name. and
Middle Inilial (MI).
11. The certifying offiCIal shall sign and date the form, print his/her name, tille. and lelephone number.
According to the Paperwork Reduction Act. as amended, no persons are reQuired to respond to a collection of information unless it displays a valid OMS Control
Number. The valid OMB control number for this Information collection is OMB No. 0348-0046. Public reporting burden for this collection of information lS
estimated 10 average 10 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
informalion. including suggestions lor reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington.
DC 20503
.""''' """
, -'
. .
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U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
OFFICE OF THE COMPTROLLER
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT, SUSPENSION AND
OTHER RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they are required to
attest. Applicants should also review the instructions for certification included in the regulations before completing this
form. Signature of this form provides for compliance with certification requirements under 28 CFR Part 69, "New
Restrictions on Lobbying" and 28 CFR Part 67, "Government-wide Debarment and Suspension (Nonpro-curement) and
Government-wide Requirements for Drug-Free Workplace (Grants)." The certifications shall be treated as a material
representation of fact upon which reliance will be placed when the Department of Justice determines to award the
covered transaction, grant, or cooperative agreement.
1. LOBBYING
As required by Section 1352, Tille 31 of the U.S. Code, and
implemented at 28 CFR Part 69, for persons enterin9 into a
grant or cooperative agreement over $1 00,000, as defined at
28 CFR Part 69. the applicant certifies thaI:
(a) No Federal appropriated funds have been paid or will be
paid, by or on behalf of the undersigned, to any person for in-
fluencing 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 con-
nection with the making of any Federal grant, the entering into
of any cooperative agreement. and the extension, continuation.
renewal, amendment, or modiflcation of any Federal grant or
cooperative agreement;
(b) If any funds other than Federal appropriated funds have
been paid or will be paid to any person for influencing or at-
tempting to influence an officer or employee of eny egency, a
Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress In connection with this
Federal grant or cooperative agreement, the undersigned shall
complete and submit Standard Form - LLL, "Disclosure of
Lobbying Activities," in accordance with its instructions;
(c) The undersigned shall require that the language of this cer-
tification be Inciuded in the award documents for all subawards
at all tiers (including sUbgrants, contracts under grants and
cooperative agreements, and subcontracts) and that all sub-
recipients shall cartify and disclose accordingly.
2. DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS
(DIRECT RECIPIENT)
As required by Executive Order 12549, Debarment and
Suspension, and implemented at 28 CFR Part 67, for prospec-
tive participants in primary covered transactions, as defined at
28 CFR Part 67, Section 67.510-
A. The applicant certifies that it and its principals:
(a) Are not presently debarred, suspended, proposed for debar-
ment, declared ineligible, sentanced to a denial of Federal
benefits by a State or Federal court, or voluntarily excluded.
from covered transactions by any Federal department
or agency;
(b) Have not within a three-year period preceding this applica-
tion been convicted of or hed a .civU Judgment rendered against
them for commission of fraud or a criminal offense In connec-
tion with obtaining, attempting to obtain, or performing a
public (Federal, State, or local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes
or commission of embezzlement, theft, forgery,
bribery. falsification or destruction of records, making false
statements, or receiving stolen property;
(c) Are not presently indicted for or otherwise criminally or
civilly charged by a governmental entity (Federal, State, or
local) with commission of any of the offenses enumerated in
paragraph (1)(b) of this certification; and
(d) Have not within a three-year period preceding this applica-
tion had one or more public transactions (Federal, State, or
local) terminated for cause or default; and
B. Where the applicant is unable to certify to any of the
statements in this certification, he or she shall attach an
explanation to this application.
3. DRUG-FREE WORKPLACE
(GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug-Frae Workplace Act of 1988, and
implemented at 28 CFR Part 67, Subpart F, for grantees, as
defined at 28 CFR Part 67 Sections 67.615 and 67.620-
A. The applicant certifies that it will or will continue to 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 an on-going 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-fnee workplace;
(3) Any available drug counseling, rehabilitation, and employee
assistance programs; and
(4) The penalties that may be imposed upon amployees for
drug abuse violations occurring in the workpiece;
(c) Making It a requirement that each employee to be engaged
in the performance of the grant be given a copy of the state-
ment required by paragraph (a);
(d) Notifying the employee in the statement required by para-
graph (a) that, as a condition of employment under the grant,
the employee will-
OJP FORM 40611613-S1) R.EFLACES OJP FORMS OOS1/Z, 006113 ANO 006110 WHICH AR.E oesOLETE.
(1) Abide by the terms of the statement; and
(2) Notify the employer in writing of his or her conviction for a
violation of a criminal drug statute occurring in the workplace
no later than five calendar days after such conviction;
(e) Notifying the agency, in writing, within 10 calendar days
after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving actual notice of such convic-tion.
Employers of convicted employees must provide notice, including
position tllie, to: Department of Justice, Office of
Justice Programs, ATTN: Control Desk, 633 Indiana Avenue,
N.W., Washington, D.C. 20531. Notice shall include the iden-
tification number(s) of each affected grant;
(f) Taking one of the following actions, within 30 calendar
days of receiving notice under subparagraph (d)(2), with
respect 10 any employee who is so convicted-
(1) Taking approprlate personnel action against such an
employee, up to and including termination, consistent with the
requirements of the Rehabilitation Act of 1973, as amended; or
(2) Requiring such employee to participate satisfactorlly In a
drug abuse assistance or rehabilitation program approved for
such purposes by a Federal, Stale, or local health, law enforce-
ment, 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 may 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)
Check 0 if there are workplaces on file that are not indentified
here.
Section 67, 630 of the regulations provides that a grantee that
is a State may elect to make one certification in each Federal
fiscal year. A copy of which should be Included with each ap-
plication for Department of Justice funding. States and State
agencies may elect to fJSe OJP Form 406117.
Check 0 if the State has elected to complete OJP Form
406117.
DRUG-FREE WORKPLACE
(GRANTEES WHO ARE INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and
implemented at 28 CFR Part 67, Subpart F, for grantees, as
defined at 26 CFR Part 67: Sections 67.615 and 67.620-
A. As a condition of the grant, 1 certify that I will not engage
in the unlawiul manufacture, distribution, dispensing, posses-
sion, or use of a controlled substance in conducting any
activity with the grant; and
B. If convicted of a criminal drug offense resulting from a
violation occurring during the conduct of any grant activity, I
will report the conviction, In writing, within 10 calendar days
of the conviction, to: Department of Justice, Office of Justice
Progrems, ATTN: Control Desk, 810 Seventh Street NW.,
Washington, DC 20531.
As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above certifications.
1. Grantee Name and Address:
County of Frederick, VA
107 North Kent Street
Winchester, VA 22601
2003-11, Office of Domestic Preparedness State Homeland Sec. Grant rog
2. Application Number and/or Project Name 3. Grantee IRSNendor Number
Mr. Gary A. DuBrueler, Director
4. Typed Name and Title of Authorized Representative
Tax 10#54-6001290
8/14/03
5. Signature
6. Date
-U,S. Govemmen.t Prinlng 0fIk:e: 1996. 405-0'37/40014