c. Sheriff-state surplus program eligibility application

SFN 17726(10-2011) NONDISCRIMINATION ASSURANCE This Assurance must be executed by the Administrative Official of the Agency/Organization prior to receiving surplus personal property from the State Agency for Surplus Property. Name of Agency/Organization I HEREBY AGREE that the program or in connection with which any property is donated to the donee,will be conducted in compliance with, and the donee will comply with and will require any other person (any legal entity)who through contractual or other arrangements with the donee is authorized to provide services or benefits under said program,to comply with all requirements imposed by or pursuant to the regulations of the General Services Administration under provisions of Title VI of the Federal Property and Administrative Services Act of 1949,as amended, Section 504 of the Rehabilitation Act of 1973,as amended,Title VI of the Civil Rights Act of 1964, as amended;Title IX of the Education Amendments of 1972, as amended,the Civil Rights Restoration Act of 1987, and Section 303 of the Age Discrimination Act of 1975, as amended to the end that no person in the United States of America shall on the grounds of race, color, national origin, sex, or age,or that no otherwise qualified handicapped person shall solely by reason of the handicap be excluded from participation in, be denied the benefits of,or be subjected to discrimination under any program or activity for which the donee received Federal assistance from the General Services Administration; and HEREBY GIVES A SSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. I further agree that this agreement shall be subject in all respects to the provisions of said regulations;that this agreement shall obligate the donee for the period during which it retains ownership or possession of any such property;that the United States shall have the right to seek judicial enforcement of this agreement;and this agreement shall be binding upon any successor in the interest of the donee and the word "donee"as used here includes any successor in interest. Signature of Administrative Official Date