EXHIBIT 6.14
1999-2000 DONATED FOOD DISTRIBUTOR AGREEMENT
FOR DELIVERY OF END PRODUCTS CONTAINING USDA COMMODITIES
TO ELIGIBLE AGENCIES IN THE STATE OF CALIFORNIA
This Donated Food Distributor Agreement is hereby entered into between
Diggy Foods, Inc. (hereinafter called Processor) and
------------------
(Processor)
ASR Food Distributor (hereinafter called Distributor).
--------------------
(Distributor)
Said distributor agrees to perform as its part of this agreement, the pickup and
distribution of food items containing United States Department of Agriculture
(USDA) donated foods to eligible recipient agencies (RA) in California.
The distributors responsibilities include:
1. The distributor agrees to deliver the processor's products containing USDA
donated foods only to eligible RAs for whom the end products were received
and who participate in the USDA Commodity Food Program. The distributor
agrees to place orders with processors for end products based on orders
from RAs.
2. The distributor is aware and agrees that if the end products containing
USDA donated foods are delivered to ineligible RAs, the distributor will be
billed by the processor for the value of USDA donated foods contained in
the end product. The fair value of the donated foods and the eligibility of
an agency will be as determined by the State Distributing Agency (DA).
3. The distributor must maintain supporting inventory records inclusive of
signed receipts and delivery receipts. As a minimum, the supporting records
must reflect:
A. Quantities of end products on hand at the beginning of the month.
B. Quantities of end products received from processor for the month.
C. Quantities of end products delivered to each RA for the month. The
distributor must ensure that delivery tickets or bills of lading for
products delivered to eligible RAs contain the following:
a. Name of receiving agency.
b. Date product received.
c. Processor name.
d. Quantities of end products delivered.
e. End product code number.
f. End product name and packsize.
g. End product price with donated food.
D. Quantities of end products on hand at end of each month.
4. If processor operates under the California Value-Pass-Through system, the
distributor must prepare and submit a Monthly Distributor Summary report to
processor for the past 30 days activity by the 8th of the month. The report
must be supported by signed delivery vouchers from RAs. As a minimum, the
Monthly Distributor Summary report must contain the following items of
information:
A. RA name and agency number.
B. Processor name.
C. Quantities of end products delivered.
D. End product code number.
E. A certification signed by the distributor stating the contract value of
the USDA commodities contained in each case of end product has passed on
to the RA in the form of a discount.
5. The distributor must produce copies of delivery documents to validate the
processor's random sample of reports when requested by the processor.
6. The distributor must cooperate with the processor, DA and/or USDA in any
reverification effort required to substantiate that end product and the
value pass through have been received.
7. The distributor shall retain all records pertaining to the pickup and/or
distribution of end products containing USDA commodities for three (3)
years from the close of the federal fiscal year to which they pertain or
longer if required for resolution of an audit or litigation. All records
shall be made available for inspection by representatives of the processor,
DA and/or USDA at any time, without prior notice, during normal office
hours. Representatives of DA and USDA shall have the right to inspect
products of processors containing USDA donated food and substituted
commercial food in the possession of distributor and the facilities used in
handling, storing, and transporting those products.
This agreement shall become effective on 5-21, 1999 and will terminate on June
30, 2000. This agreement may be terminated by either party upon 30 days written
notice to the other.
This agreement shall be terminated immediately upon determination by either the
DA or the USDA of noncompliance by the distributor with any of the terms and
conditions of this agreement. A finding of noncompliance may be cause for
termination of Donated Food Distributor Agreements with all other processors
with whom distributor does business. Noncompliance findings may also subject the
distributor to criminal or civil prosecution.
The distributor recognizes and accepts the facts that this is not an exclusive
agreement. Distributor assures it will not interfere with processor's right to
deliver products through other distributors. DA warehouses, or direct to
recipient agencies.
ASR Food Distributors 5-21-99
------------------------------------------------------------------------
Distributor Name: Date:
0000 Xxxx Xxxxxx Xxxxxxxx, XX 00000
------------------------------------------------------------------------
Address: City, State, Zip
illegible President 323 8904525
------------------------------------------------------------------------
Signature: Title: Phone:
XXXX Foundation, Inc./Dippy Foods, Inc.
------------------------------------------------------------------------
Processor Name Date:
Xxxx Xxxx General Manager 714 220-0224
------------------------------------------------------------------------
Signature: Title: Phone:
STATE DISTRIBUTING AGENCY APPROVAL:
Xxxx Xxxxx Manager
----------------------- ----------------------
(Name) (Title)
Xxxx Xxxxx 6-29-99
----------------------- ----------------------
(Signature) (Date)
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW Basis of Price (check):
X Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA SCHEDULE Contract Year: 1999-2000
--
Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD EXCLUDING POULTRY FOB Plant X
--- ---
Revised Schedule Short Title PB10 Commodity Code 6475 Delivered
--- ----------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place "DF" of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Xxxxx Xxxxx Dippers 18.13 40 2.00 PB 10 DF 5.50
82325
--------------------------------------------------------------------------------------------
2.50 Xxxxx Xxxxx Apple 6.25
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortilla 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.63
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of "XX Xxxxx allowable
per raw case of end manufacture contained not using pound Value "DF" Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Xxxxx Xxxxx Dippers 1.00 5.50 91.00 5.00 $34.00 $0.77 $3.85 $30.15
82325
---------------------------------------------------------------------------------------------------------------------
6.25 6.25
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.13 $34.00 $3.85 $30.15
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW
Basis of Price (check):
X Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA
SCHEDULE Contract Year: 1999-2000
---
X Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD
EXCLUDING POULTRY FOB Plant
---
---
Revised Schedule Short Title PB RDU-FAT 10 Commodity Code 6476 Delivered
--- ------------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place 'DF' of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Cherry Dippers 18.13 40 2.00 PB RDU-FAT 10 DF 5.50
81303
--------------------------------------------------------------------------------------------
2.50 Cherry Apple Fruit 6.25
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortillas 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.63
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of 'DF' Price allowable
per raw case of end manufacture contained not using pound Value 'DF' Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Cherry Dippers 1.00 5.50 91.00 5.00 $34.00 $1.03 $5.16 $28.84
81303
---------------------------------------------------------------------------------------------------------------------
6.25 6.25
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.13 $34.00 $5.16 $28.84
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only illegible
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW Basis of Price (check):
Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA SCHEDULE Contract Year: 1999-2000
Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD EXCLUDING POULTRY FOB Plant X
--- ---
Revised Schedule Short Title PB RDU-FAT 10 Commodity Code 6475 Delivered
--- ------------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place "DF" of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Pineapple Dippers 18.13 40 2.00 PB 10 DF 5.50
82314
--------------------------------------------------------------------------------------------
2.50 Pineapple Apple 6.25
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortillas 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.63
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of "DF" Price allowable
per raw case of end manufacture contained not using pound Value "DF" Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Pineapple Dippers 1.00 5.50 91.00 5.00 $34.00 $0.77 $3.85 $30.15
82314
---------------------------------------------------------------------------------------------------------------------
6.25 6.25
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.13 $34.00 $3.85 $30.15
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only illegible
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW Basis of Price (check):
X Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA SCHEDULE Contract Year: 1999-2000
---
Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD EXCLUDING POULTRY FOB Plant X
--- ---
Revised Schedule Short Title PB RDU-FAT 10 Commodity Code 6475 Delivered
--- ------------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place "DF" of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Cherry Dippers 18.13 40 2.00 PB 10 DF 5.50
82303
--------------------------------------------------------------------------------------------
2.50 Apple Cherry 6.25
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortillas 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.63
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of "DF" Price allowable
per raw case of end manufacture contained not using pound Value "DF" Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Cherry Dippers 1.00 5.50 91.00 5.00 $91.00 $0.77 $3.85 $87.15
82303
---------------------------------------------------------------------------------------------------------------------
6.25 6.25
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.13 $91.00 $3.85 $87.15
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW Basis of Price (check):
X Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA SCHEDULE Contract Year: 1999-2000
---
Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD EXCLUDING POULTRY FOB Plant X
--- ---
Revised Schedule Short Title PB RDU-FAT 10 Commodity Code 6476 Delivered
--- ------------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place "DF" of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Xxxxx Xxxxx Dippers 18.13 40 2.00 PB RDU-FAT 10 DF 5.50
81325
--------------------------------------------------------------------------------------------
2.50 Xxxxx Xxxxx Apple 6.26
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortillas 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.64
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of "DF" Price allowable
per raw case of end manufacture contained not using pound Value "DF" Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Xxxxx Xxxxx Dippers 1.00 5.50 91.00 5.00 $34.00 $1.03 $5.16 $28.84
81325
---------------------------------------------------------------------------------------------------------------------
6.26 6.26
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.14 $34.00 $5.16 $28.84
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
THIS IS AN ORIGINAL SCHEDULE UNLESS CHECKED BELOW Basis of Price (check):
X Original Schedule (Submitted w/Agreement no Change) END PRODUCT DATA SCHEDULE Contract Year: 1999-2000
---
Additional Schedule (Submitted after Agreement Approval) ALL DONATED FOOD EXCLUDING POULTRY FOB Plant X
--- ---
Revised Schedule Short Title PB RDU-FAT 10 Commodity Code 6476 Delivered
--- ------------- ------- ---
Other
---
--------------------------------------------------------------------------------------------
PRODUCT FORMULATION
END PRODUCT DESCRIPTION RAW BATCH BASIS
--------------------------------------------------------------------------------------------
Net
Size weight, Name raw ingredients Quantity
Net and/or in ounces, in batch; place "DF" of each
End product label name, weight servings or portion after each donated item in
type, code number, etc. per case per case component food. pounds
1 2 3 4 5 6
--------------------------------------------------------------------------------------------
Pineapple Dippers 18.13 40 2.00 PB RDU-FAT 10 DF 5.50
81325
--------------------------------------------------------------------------------------------
2.50 Pineapple Apple 6.26
Fruit
--------------------------------------------------------------------------------------------
2.75 Cinnamon Tortillas 6.88
Chips
--------------------------------------------------------------------------------------------
TOTALS Total portion weight 7.25 Total batch weight 18.64
--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------
END PRODUCT RETURN
BASED ON PRODUCTION DONATED FOOD VALUE
---------------------------------------------------------------------------------------------------------------------
Pounds Lbs. of Dollars
Number "DF" to Percentage each Case per
of cases make one of "DF" Price allowable
per raw case of end manufacture contained not using pound Value "DF" Net case
batch product yield per case "DF" of "DF" per case price
7 8 9 10 11 12 13 14
---------------------------------------------------------------------------------------------------------------------
Pineapple Dippers 1.00 5.50 91.00 5.00 $34.00 $1.03 $5.16 $28.84
81325
---------------------------------------------------------------------------------------------------------------------
6.26 6.25
---------------------------------------------------------------------------------------------------------------------
6.88 6.88
---------------------------------------------------------------------------------------------------------------------
TOTALS 18.13 $34.00 $5.16 $28.84
---------------------------------------------------------------------------------------------------------------------
-----------------------------------------------
By-products other than rework will be product YES NO X If yes PLEASE PRINT OR TYPE
refer to Articles 12 and 35 for further requirements.
CERTIFICATION REQUIRED: (DA must indicate option required) Dippy Foods Inc./Feedback Foundation
------------------------------------
Name of Company
Donated Poultry Requires (Option 1)
------ Xxx Xxxxxxxxx
------------------------------------
Donated Poultry (Option 2) Name of Authorized Representative
Donated Meat Requires Option 1 President
Certification on Nonsubstitution ------------------------------------
and Nondiversion Title of Authorized Representative
------
Xxx Xxxxxxxxx 6-26-99
------------------------------------
Signature Date Signed
-----------------------------------------------
Optional 2 Metal Detection Only
------ ------------------------------------
State Agency Approval Signature
Option 2 Additional Requirements
Attached and signed by DA and
Processor CA 7/1/99
------ ------------------------------------
State Effective Date
-----------------------------------------------
FORMULATION, RETURN, AND FEE FOR SERVICE CANNOT BE CHANGED DURING THE AGREEMENT
PERIOD WITHOUT PRIOR APPROVAL OF DA.
U.S. DEPARTMENT OF AGRICULTURE
--------------------------------------------------------------------------------
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, 7 CFR Part 3017, Section 3017.510,
Participants' responsibilities. The regulations were published as Part IV of the
January 30, 1989, Federal Register (pages 4722-4733). Copies of the regulations
may be obtained by contacting the Department of Agriculture agency with which
this transaction originated.
(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 is 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.
Feedback Foundation, Inc.
--------------------------------------------------------------------------------
Organization Name PR/Award Number or Project Name
Xxxx Xxxx General Manager
--------------------------------------------------------------------------------
Name and Title of Authorized Representative
illegible 5/21/99
--------------------------------------------------------------------------------
Signature Date
CERTIFICATION REGARDING PROVISION
OF A DRUG-FREE WORKPLACE
I, behalf of the contractor or grantee, do hereby certify that the
contractor or grantee will provide a drug-free workplace by doing all of the
following, as required by California Government Code Section 8355, as a
condition of the contract or grant:
(a) Publish a statement notifying employees that the unlawful manufacture,
distribution, dispensation, possession or use of a controlled substance is
prohibited in this person's or organization's workplace and specifying the
actions that will be taken against employees for violations of the prohibition.
(b) Establish a drug-free awareness program to inform employees aboout all
of the following:
(1) The dangers of drug abuse in the workplace.
(2) The person's or organization's policy of maintaining a drug-free
workplace.
(3) Any available drug counseling, rehabilitation and employee assistance
programs.
(4) The penalties that may be imposed upon employees for drug abuse
violations.
(c) Require that each employee engaged in the performance of the contract
or grant be given a copy of the statement required by subdivision (a) and that,
as a condition of employment on the contract or grant, the employee agrees to
abide by the terms of the statement.
The contractor or grantee understands that the contract or grant may be
subject to suspension of payments under the contract or grant or termination of
the contract or grant, or both, and the contractor or grantee thereunder may be
subject to debarment if the California Department of Education determines that
either of the following has occurred:
(1) The contractor or grantee has made a false certification.
(2) The contractor or grantee violates this certification by failing to carry
out the requirements of subdivision (a) to (c), inclusive, above.
--------------------------------------------------------------------------------
Organization Name
FEEDBACK FOUNDATION, INC.
--------------------------------------------------------------------------------
Name and Title of Authorized Representative
Xxxx Xxxx, General Manager
--------------------------------------------------------------------------------
Signature Date
illegible August 14, 1998
--------------------------------------------------------------------------------
illegible 5/21/99
