OMB Burden Disclosure Statement
___________________________________________________(Hereinafter called the
"Applicant") HEREBY AGREES to comply with Title VI of the Civil Rights Act of 1964
(Pub. L. 88-352), Section 16 of the Federal Energy Administration Act of 1974
(Pub. L. 93-275), Section 401 of the Energy Reorganization Act of 1974
(Pub. L. 93-438), Title IX of the Education Amendments of 1972, as amended,
(Pub. L. 92-318, Pub. L. 93-568, and Pub. L. 94-482), Section 504 of the
Rehabilitation Act of 1973 (Pub. L. 93-112), the Age Discrimination Act of
1975 (Pub. L. 94-135), Title VIII of the Civil Rights Act of 1968
(Pub. L.90-284), the Department of Energy Organization Act of 1977
(Pub. L. 95-91), the Energy Conservation and Production Act of 1976, as
amended, (Pub. L. 94-385) and Title 10, Code of Federal Regulations, Part
1040. In accordance with the above laws and regulations issued pursuant
thereto, the Applicant agrees to assure that no person in the United States
shall, on the ground of race, color, national origin, sex, age, or disability,
be excluded from participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity in which the
Applicant receives Federal assistance from the Department of Energy.
Applicability and Period of Obligation
In the case of any service, financial aid, covered employment, equipment,
property, or structure provided, leased, or improved with Federal assistance
extended to the Applicant by the Department of Energy, this assurance
obligates the Applicant for the period during which Federal assistance is
extended. In the case of any transfer of such service, financial aid,
equipment, property, or structure, this assurance obligates the transferee for
the period during which Federal assistance is extended. If any personal
property is so provided, this assurance obligates the Applicant for the period
during which it retains ownership or possession of the property. In all other
cases, this assurance obligates the Applicant for the period during which the
Federal assistance is extended to the Applicant by the Department of Energy.
Employment Practices
Where a primary objective of the Federal assistance is to provide employment
or where the Applicant's employment practices affect the delivery of services
in programs or activities resulting from Federal assistance extended by the
Department, the Applicant agrees not to discriminate on the ground of race,
color, national origin, sex, age, or disability, in its employment practices.
Such employment practices may include, but are not limited to, recruitment,
advertising, hiring, layoff or termination, promotion, demotion, transfer,
rates of pay, training and participation in upward mobility programs; or other
forms of compensation and use of facilities.
Subrecipient Assurance
The Applicant shall require any individual, organization, or other entity with
whom it subcontracts, subgrants, or subleases for the purpose of providing any
service, financial aid, equipment, property, or structure to comply with laws
and regulations cited above. To this end, the subrecipient shall be required
to sign a written assurance form; however, the obligation of both recipient
and subrecipient to ensure compliance is not relieved by the collection or
submission of written assurance forms.
Data Collection and Access to Records
The Applicant agrees to compile and maintain information pertaining to
programs or activities developed as a result of the Applicant's receipt of
Federal assistance from the Department of Energy. Such information shall
include, but is not limited to the following: (1) the manner in which services
are or will be provided and related data necessary for determining whether any
persons are or will be denied such services on the basis of prohibited
discrimination; (2) the population eligible to be served by race, color,
national origin, sex, age, and disability; (3) data regarding covered
employment including use or planned use of bilingual public contact employees
serving beneficiaries of the program where necessary to permit effective
participation by beneficiaries unable to speak or understand English; (4) the
location of existing or proposed facilities connected with the program and
related information adequate for determining whether the location has or will
have the effect of unnecessarily denying access to any person on the basis of
prohibited discrimination; (5) the present or proposed membership by race,
color, national origin, sex, age and disability in any planning or advisory
body which is an integral part of the program; and (6) any additional written
data determined by the Department of Energy to be relevant to the obligation
to assure compliance by recipients with laws cited in the first paragraph of
this assurance.
The Applicant agrees to submit requested data to the Department of Energy
regarding programs and activities developed by the Applicant from the use of
Federal assistance funds extended by the Department of Energy. Facilities of
the Applicant (including the physical plants, buildings, or other structures)
and all records, books, accounts, and other sources of information pertinent
to the Applicant's compliance with the civil rights laws shall be made
available for inspection during normal business hours on request of an officer
or employee of the Department of Energy specifically authorized to make such
inspections. Instructions in this regard will be provided by the Director,
Office of Civil Rights, U.S. Department of Energy.
This assurance is given in consideration of and for the purpose of obtaining
any and all Federal grants, loans, contracts (excluding procurement
contracts), property, discounts or other Federal assistance extended after the
date hereof, to the Applicants by the Department of Energy, including
installment payments on account after such data of application for Federal
assistance which are approved before such date. The Applicant recognizes and
agrees that such Federal assistance will be extended in reliance upon the
representations and agreements made in this assurance, and that the United
States shall have the right to seek judicial enforcement of this assurance.
This assurance is binding on the Applicant, the successors, transferees, and
assignees, as well as the person(s) whose signatures appear below and who are
authorized to sign this assurance on behalf of the Applicant.
The Applicant certifies that it has complied, or that, within 90 days of the
date of the grant, it will comply with all applicable requirements, of 10
C.F.R. 1040.5 (a copy will be furnished to the Applicant upon written
request to DOE).
Designated Responsible Employee
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Applicant Certification
Name and Title (Printed or Typed) and Telephone Number
Signature and Date
Applicant's Name and Telephone Number
Address
Date
Authorized Official:
President, Chief Executive Officer
or Authorized Designee
Name and Title (Printed or Typed) and Telephone Number
Signature and Date