Common use of Certification Form Clause in Contracts

Certification Form. Contractor shall annually submit to the Village Contractor’s certifications as required in Attachment C to this Agreement, in the attached in Attachment D I hereby certify that I am the of 1. Not delinquent in the payment of taxes to the Illinois Department of Employment security or the Illinois Department of revenue in accordance with 65 ILCS 5/11-42.1-1; 2. Not barred from contracting as a result of a violation of either Section 33E-3 (bid-rigging) or 33E-4 (bid-totaling) of the Criminal Code of 1961, and as amended from time to time (720 ILCS 5/33E-3 and 5/33E-4); and 3. Not in default, as defined in 5 ILCS 385/2, on an educational loan, as defined in 5 ILCS 385/1. In addition, Contractor hereby represents and warrants to the Village of Frankfort, Illinois, as a condition of any agreement with the Village of Frankfort, Illinois, that Contractor is under no legal prohibition on contracting with the Village, has no known conflicts of interest, and further certifies that: 1. Contractor maintains and will maintain a drug-free workplace in accordance with the Drug Free Workplace Act (30 ILCS 580/1 et seq.) by: A. Publishing a statement: (1) Notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance including cannabis, is prohibited in Contractor’s workplace; (2) Specifying the actions that will be taken against employee for violations of such prohibition; (3) Notifying the employee that, as a condition of employment on this Agreement, the employee will: a. Abide by the terms of the statement; and b. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction. B. Establishing a drug-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) Contractor’s policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) The penalties that may be imposed upon employees for drug violations. C. Making it a requirement to give a copy of the statement required by subsection A to each employee engaged in the performance of the Agreement, and to post the statement in a prominent place in the workplace. D. Notifying the Village within ten (10) days after receiving notice under Paragraph A.3(b) from an employee or otherwise receiving actual notice of such conviction. E. Imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted, as required by 30 ILCS 580/5. F. Assisting employees in selecting a course of action in the event drug counseling treatment and rehabilitation is required and indicating that a trained referral team is in place; and G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of this section. 2. It has an Illinois Department of Human Rights pre-qualification number or has properly completed application for a Department pre-qualification number on file with the Department, as provided for in 44 Illinois Administrative Code 750.210. 3. No Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village officer or trust in which a Village officer, spouse or dependent child of a Village officer or a beneficiary is a holder of any interest in Contractor; or, no Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village officer or trust in which a Village officer, spouse or dependent child of a Village officer or a beneficiary is a holder of more than one percent (1%) of Contractor, but if any Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village office or trust in which a Village officer, spouse or dependent child of a Village officer or beneficiary is a holder of less than one percent (1%) of Contractor, Contractor has disclosed to the Village in writing the name(s) of the holder of such interest. 4. No officer or employee of the Village has solicited any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer from Contractor. 5. Contractor has not given to any officer or employee of the Village any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer. 6. Neither Contractor nor any of its principals, shareholders, members, partners or affiliates, as applicable, is a person or entity names as a Specially Designated National and Blocked person (as defined in Presidential Executive Order 13224) and that it is not acting, directly or indirectly, for or on behalf of a Specially Designated National and Blocker Person and that

Certification Form. Contractor shall annually submit to the Village Contractor’s certifications as required in Attachment C to this Agreement, in the attached in Attachment D I hereby certify that I am the ofof ________________________________ (“Contractor’) and as such hereby represent and warrant to the Village of Dolton, Illinois, as a condition of any agreement with the Village of Dolton, that Contractor, its shareholders holding more than five (5%) percent of the outstanding shares of the corporation, its offices and directors are: 1. Not delinquent in the payment of taxes to the Illinois Department of Employment security or the Illinois Department of revenue in accordance with 65 ILCS 5/11-42.1-1; 2. Not barred from contracting as a result of a violation of either Section 33E-3 (bid-rigging) or 33E-4 (bid-totaling) of the Criminal Code of 1961, and as amended from time to time (720 ILCS 5/33E-3 and 5/33E-4); and 3. Not in default, as defined in 5 ILCS 385/2, on an educational loan, as defined in 5 ILCS 385/1. In addition, Contractor hereby represents and warrants to the Village of FrankfortDolton, Illinois, as a condition of any agreement with the Village of FrankfortDolton, Illinois, that Contractor is under no legal prohibition on contracting with the Village, has no known conflicts of interest, and further certifies that: 1. Contractor maintains and will maintain a drug-free workplace in accordance with the Drug Free Workplace Act (30 ILCS 580/1 et seq.) by: A. Publishing a statement: (1) Notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance including cannabis, is prohibited in Contractor’s workplace; (2) Specifying the actions that will be taken against employee for violations of such prohibition; (3) Notifying the employee that, as a condition of employment on this Agreement, the employee will: a. Abide by the terms of the statement; and b. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction. B. Establishing a drug-free awareness program to inform employees about: (1) The dangers of drug abuse in the workplace; (2) Contractor’s policy of maintaining a drug-free workplace; (3) Any available drug counseling, rehabilitation, and employee assistance program; and (4) The penalties that may be imposed upon employees for drug violations. C. Making it a requirement to give a copy of the statement required by subsection A to each employee engaged in the performance of the Agreement, and to post the statement in a prominent place in the workplace. D. Notifying the Village within ten (10) days after receiving notice under Paragraph A.3(b) from an employee or otherwise receiving actual notice of such conviction. E. Imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by any employee who is so convicted, as required by 30 ILCS 580/5. F. Assisting employees in selecting a course of action in the event drug counseling treatment and rehabilitation is required and indicating that a trained referral team is in place; and G. Making a good faith effort to continue to maintain a drug-free workplace through implementation of this section. 2. It has an Illinois Department of Human Rights pre-qualification number or has properly completed application for a Department pre-qualification number on file with the Department, as provided for in 44 Illinois Administrative Code 750.210. 3. No Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village officer or trust in which a Village officer, spouse or dependent child of a Village officer or a beneficiary is a holder of any interest in Contractor; or, no Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village officer or trust in which a Village officer, spouse or dependent child of a Village officer or a beneficiary is a holder of more than one percent (1%) of Contractor, but if any Village officer, spouse or dependent child of a Village officer, agent on behalf of any Village office or trust in which a Village officer, spouse or dependent child of a Village officer or beneficiary is a holder of less than one percent (1%) of Contractor, Contractor has disclosed to the Village in writing the name(s) of the holder of such interest. 4. No officer or employee of the Village has solicited any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer from Contractor. 5. Contractor has not given to any officer or employee of the Village any gratuity, discount, entertainment, hospitality, loan, forbearance, or other tangible or intangible item having monetary value including, but not limited to, cash, food and drink, and honoraria for speaking engagements related to or attributable to the government employment or the official position of the employee or officer. 6. Neither Contractor nor any of its principals, shareholders, members, partners or affiliates, as applicable, is a person or entity names as a Specially Designated National and Blocked person (as defined in Presidential Executive Order 13224) and that it is not acting, directly or indirectly, for or on behalf of a Specially Designated National and Blocker Person and that