Va Form 40-0895-9 - Certification Regarding Lobbying
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1OMB NUMBER: 2900-0559
Respondent Burden: 15 minutes
CERTIFICATION REGARDING LOBBYING
Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory
authority for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal
government has complied with Public Law 101-121 regarding the prohibition against any payments to anyone that influences or
attempts to influence an officer or Member of Congress in connection with the award of a grant. VA may not conduct or sponsor and
you are not required to respond to this collection of information unless it displays a valid OMB number. Respond to this collection is
voluntary. Send comments regarding the burden estimate or any other aspects of this collection of information, including suggestions
for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC 20420. SEND
COMMENTS ONLY. Please do not send applications for a grant to this address.
This certification is made in compliance with Section 319 of Public Law 101-121 and pursuant to the Interim Final guidance published
on December 20, 1989 in the Federal Register (Pages 52306-52332).
Certification for Contracts, Grants, Loans, and Cooperative Agreements.
The undersigned certifies, to the best of their knowledge and belief, that:
(1) 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 any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of 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
of
any
Federal
contract,
grant,
loan,
or
cooperative
agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence 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 Forms-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 subawards 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. 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.
SIGNATURE OF STATE OR TRIBAL GOVERNMENT CERTIFYING OFFICIAL
DATE (mm/dd/yyyy)
NAME OF STATE OR TRIBAL GOVENMENT
TITLE OF STATE OR TRIBAL GOVERNMENT CERTIFYING OFFICIAL
PROJECT FAI (Federal Identification
CERTIFYING OFFICIAL
Number) NO.
NAME AND ADDRESS OF STATE OR TRIBAL GOVERNMENT AGENCY
40-0895-9
VA FORM
OCT 2010
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