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, CERTIFIES OR
S
ignature: Date:
SECTION 10C – SUPPORT DOCUMENTATION: LOBBYING
Title:
Name of the Applicant’s
authorized official:
No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of a federal department or agency, a member of the U.S.
Congress, an officer or employee of the U.S. Congress, or an employee of a member of the U.S. Congress in connection
with the awarding of any federal Contract, the making of any federal grant, the making of any federal loan, the entering into
of any cooperative agreement, and the extension, continuation, renewal, amendment or modification thereof.
If any funds other than federal appropriated funds have been paid or will be paid to any person for making lobbying contacts
to an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a
member of Congress in connection with this federal Contract, grant, loan or cooperative agreement, the undersigned shall
complete and submit Standard Form LLL, “Disclosure Form to Report Lobbying,” in accordance with its instruction, as
amended by “Government-wide Guidance for New Restrictions on Lobbying,” 61 Fed. Reg. 1413 (1/19/96).
The undersigned shall require that the language of this certification be included in the award documents for all sub-awards
at all tiers (including subcontracts, sub-grants and contracts under grants, loans and cooperative agreements) and that all
sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance
was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by 31, USC § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any
person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than
$100,000 for each such failure.
Lobbying
Byrd Anti-Lobbying Amendment, 31 U.S.C. 1352, as amended by
the Lobbying Disclosure Act of 1995, P.L. 104-65 [to be
codified at 2 U.S.C. § 1601, et seq.] - Agencies who apply for an award of $100,000 or more shall file the certification required by
49 CFR part 20, "New Restrictions on Lobbying." Each tier certifies to the tier above that it will not and has not used Federal
appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any
agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with
obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier shall also disclose the name of
any registrant under the Lobbying Disclosure Act of 1995 who has made lobbying contacts on its behalf with non-Federal funds
with respect to that Federal contract, grant or award covered by 31 U.S.C. 1352. Such disclosures are forwarded from tier to tier
up to the recipient. The "Lobbying Certification" form must be completed, signed and submitted with Contractor’s bid.
Lobbying Certification
This form is to be submitted with a grant application exceeding $100,000.
The Applicant certifies, to the best of its knowledge and belief, that:
AFFIRMS THE
TRUTHFULNESS
AND
ACCURACY
O
F EACH
STATEMEN
T O
F ITS
CERTIFICATION
AND DISCLOSURE,
IF ANY. IN ADDITION, THE APPLICANT UNDERSTANDS AND AGREES THAT THE PROVISIONS OF 31 USC §§ 3801 ET
SEQ. APPLY TO THIS CERTIFICATION AND DISCLOSURE, IF ANY.
THE APPLICANT,
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