Lobbying Certification Form - 2013
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1LOBBYING CERTIFICATION FORM
Certification Regarding Lobbying for Contracts, Grants, Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
1.
No State or 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 legislation or appropriation
actions pending before local, State and Federal executive and/or legislative bodies in connection
with the awarding of any contract, the making of any grant, the making of any loan, the entering
into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any contract, grant, loan, or cooperative agreement.
2.
If any funds other than State of Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence legislation or appropriation actions pending
before local, State and Federal executive and/or legislative bodies in connection with this
contract, grant, loan or cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.
3.
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, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients 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 Section 1352, Title 31, U.S. Code. Failure to file the required certification shall be
subject to civil penalty by the Federal government of not less than $10,000 and not more than $100,000
for each such failure.
Provider:
________________________________________
Agreement Number:____________________________________
Sign:
_________________________________________
Name:
_________________________________________
Title:
_________________________________________
Date:
_________________________________________
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Revised 6/24/13
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