LOBBYINGCERTIFICATIONFORM
CertificationforContracts, Grants, Loans, andCooperativeAgreements
Theundersignedcertifies, to thebest ofhis orherknowledge and belief, that:
(1) Nofederalappropriated fundshavebeen paidorwillbepaid, byoronbehalfoftheundersigned, toany personforinfluencingorattemptingtoinfluenceanofficeroremployeeofanyagency,amemberof Congress,anofficeror employee of Congress,oranemployee ofa memberof Congressinconnectionwiththe awardingofanyfederalcontract,themakingofanyfederalgrant,themakingofany federalloan,theentering into of anycooperativeagreement,and theextension, continuation, renewal, amendment, ormodification of any federal contract,grant, loan, or cooperative agreement.
(2) Ifanyfundsotherthanfederalappropriatedfundshavebeenpaidorwillbepaidtoanyperson forinfluencingorattemptingtoinfluenceanofficeroremployeeofanyagency,amemberofCongress,an officeroremployeeofCongress,oranemployee of amemberofCongressinconnectionwiththisfederal contract,grant,loan,or cooperative agreement,the undersignedshallcomplete andsubmitStandardForm-LLL, "DisclosureofLobbying Activities,"in accordancewith its instructions.
(3) The undersignedshallrequire thatthe languageof thiscertificationbe includedinthe award documentsforallsubawardsatalltiers(includingsubcontracts,subgrants,andcontractsundergrants,loans, and cooperativeagreements) and that all subrecipients shall certifyand disclose accordingly.
Thiscertificationisa materialrepresentationof factuponwhichrelianceisplacedwhenthistransactionwas madeorenteredinto. Submissionofthiscertificationisa prerequisiteformakingorentering intothis transactionimposedunderSection1352,Title31,U.S.Code. Any personwhofailstofiletherequired certificationshallbesubjecttoacivilpenalty ofnotlessthan$10,000andnotmorethan$100,000forsuch failure.
SIGNATURE:
TITLE:
DATE:
Page 1 of 3
DISCLOSURE OF LOBBYING ACTIVITIES ApprovedbyOMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:a. contract b. grant
c. cooperative agreement d. loan
e. loan guarantee f. loan insurance / 2. Status of Federal Action:
a. bid/offer/application b. initial award
c. post-award / 3. Report Type:
a. initial filing
b. material change
For Material Change Only:
year quarter
date of last report
4. Name and Address of Reporting Entity:
PrimeSubawardee
Tier , if known:
Congressional District,if known: / 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime:
Congressional District,if known:
6. Federal Department/Agency: / 7. Federal Program Name/Description:
CFDA Number,if applicable:
8. Federal Action Number, if known: / 9. Award Amount,if known:
$
10. a. Name and Address of Lobbying Registrantb. Individuals Performing Services(including address if
(if individual, last name, first name, MI): / different from No. 10a)
(last name, first name, MI):
11.Informationrequestedthroughthisformisauthorizedbytitle31U.S.C.section
1352. Thisdisclosure oflobbyingactivitiesis amaterial representation offact
uponwhichreliancewasplacedbythetierabove whenthistransactionwasmade or enteredinto. Thisdisclosureisrequiredpursuantto31U.S.C.1352. This information willbeavailablefor public inspection. Any person who fails to file the requireddisclosureshall be subject to a civil penalty of not less than $10,000 and not morethan$100,000for each such failure. / Signature: Print Name: Title: Telephone No.: Date:
Federal Use Only: / AuthorizedforLocalReproduction
StandardFormLLL(Rev.7-97)
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
Thisdisclosureformshallbecompletedbythe reportingentity,whethersubawardeeorprimeFederalrecipient,atthe initiationorreceiptofacoveredFederal action,oramaterialchangetoapreviousfiling,pursuanttotitle31U.S.C.section1352.Thefilingofa formisrequiredforeachpaymentoragreementtomake paymenttoanylobbyingentityforinfluencingorattemptingtoinfluenceanofficeroremployeeofanyagency,a MemberofCongress,anofficer oremployeeof Congress,oranemployeeofaMemberofCongressinconnectionwithacoveredFederalaction.Completeallitemsthatapplyforboththeinitialfilingandmaterial changereport.RefertotheimplementingguidancepublishedbytheOfficeofManagementandBudgetforadditionalinformation.
1.IdentifythetypeofcoveredFederalactionforwhichlobbyingactivityisand/orhasbeensecuredtoinfluencetheoutcomeofacoveredFederalaction.
2.IdentifythestatusofthecoveredFederalaction.
3.Identifytheappropriateclassificationofthisreport.Ifthisisa followupreportcausedbya materialchangetotheinformationpreviouslyreported,enter theyearandquarterinwhichthechangeoccurred.Enterthedateofthelast previouslysubmittedreportbythisreportingentityforthiscoveredFederal action.
4.Enterthefullname,address,city,Stateandzipcodeofthereportingentity.IncludeCongressionalDistrict,ifknown.Checktheappropriateclassification ofthereportingentitythatdesignatesif itis,orexpectstobe,aprimeorsubawardrecipient.Identifythetierof thesubawardee,e.g.,thefirstsubawardee oftheprimeisthe1sttier.Subawardsincludebutarenotlimitedtosubcontracts,subgrantsandcontractawardsundergrants.
5.Iftheorganizationfilingthereportinitem4checks"Subawardee,"thenenterthefullname,address,city,StateandzipcodeoftheprimeFederal recipient.IncludeCongressionalDistrict,ifknown.
6.EnterthenameoftheFederalagencymakingtheawardorloancommitment.Includeatleastoneorganizationallevelbelowagencyname,ifknown.For example,DepartmentofTransportation,UnitedStatesCoastGuard.
7.EntertheFederalprogramnameordescriptionforthecoveredFederalaction(item1).Ifknown,enterthefullCatalogofFederalDomesticAssistance
(CFDA)numberforgrants,cooperativeagreements,loans,andloancommitments.
8.EnterthemostappropriateFederalidentifyingnumberavailablefortheFederalactionidentifiedinitem1(e.g.,RequestforProposal(RFP)number; InvitationforBid(IFB)number;grantannouncementnumber;thecontract,grant,orloanawardnumber;theapplication/proposalcontrolnumber assignedbytheFederalagency).Includeprefixes,e.g.,"RFP-DE-90-001."
9.Fora coveredFederalactionwheretherehasbeenanawardorloancommitmentbythe Federalagency,enterthe Federalamountofthe award/loan commitmentfortheprimeentityidentifiedinitem4or5.
10.(a)Enterthefullname,address,city,StateandzipcodeofthelobbyingregistrantundertheLobbyingDisclosureActof1995engagedbythereporting entityidentifiedinitem4toinfluencethecoveredFederalaction.
(b)Enterthefullnamesoftheindividual(s)performingservices,andincludefulladdressifdifferentfrom10(a).EnterLastName,FirstName,and
MiddleInitial(MI).
11.Thecertifyingofficialshallsignanddatetheform,printhis/hername,title,andtelephonenumber.
AccordingtothePaperworkReductionAct,asamended,nopersonsarerequiredtorespondtoa collectionofinformationunlessitdisplaysa validOMB Control Number.ThevalidOMBcontrolnumberforthisinformationcollectionisOMBNo.0348-0046.Publicreportingburdenforthiscollectionofinformationis estimatedtoaverage10minutes perresponse,includingtimeforreviewinginstructions,searchingexistingdatasources,gatheringandmaintainingthedata needed,andcompletingandreviewingthecollectionofinformation.Sendcomments regardingtheburdenestimateoranyotheraspectofthiscollectionof information,includingsuggestionsforreducingthisburden,totheOfficeofManagementand Budget,PaperworkReductionProject (0348-0046),Washington, DC20503.
Page 1 of 3