1635 Quarterly Certification for Part-time Case Handlers

Instructions: This certification is to be made on a quarterly basis by each recipient of Legal Services Corporation ("LSC") funding who has one or more casehandlers (attorneys and/or paralegals) who work part-time for the recipient and part time for an organization that engages in restricted activities. These certifications are to be maintained by the recipient and are not required to be submitted to LSC. Part A covers general information. Part B should be completed by the covered employee(s) and maintained by the recipient. Part C is optional and is provided for your convenience. Part C is for those programs that do not have any staff who are covered by this regulation; it may be completed on a quarterly basis and retained with your required records.

Part A

Recipient Name:                                                                                                                                  ("Recipient")

Recipient Number:                                                          

Reporting Period: Year: 20        1st Quarter
      [Jan. - Mar.] 		2nd Quarter
       [Apr. - June.] 		3rd Quarter
      [July. - Sept.] 		4th Quarter
       [Oct. - Dec.]

Part B

Employee Name:                                                                                                                                             

Position Title:                                                                                                                                                   

Pursuant to the requirements of 45 C.F.R. §1635.3(d), I certify that (1) I have not engaged in any restricted activity during any time for which I was compensated by the Recipient, and (2) I have not used any program resources for any restricted activities.

Signed: ___________________________________________________ Date: _____________________

Note: The certification requirement does not apply to a de minimis action related to a restricted activity. Actions consistent with the de minimis standard are those that meet all or most of the following criteria: actions that are of little substance; require little time; are not initiated by the part-time employee; and, for the most part, are unavoidable.

I have reviewed the requirements of 45 C.F.R. §1635.3(d), I am not able to attest to the above certification. (Please attach a statement of explanation.)

Signed: ___________________________________________________

 Date: _____________________

Part C (Optional)

On or about __________, 20____[Date], I conducted a review of Program staff for compliance with 45 C.F.R. Part 1635. During the period set forth above, there were no employees who were covered by this regulation.

Signed:__________________________________________________