DISCLOSURE OF LOBBYING ACTIVITIES
The undersigned [Contractor] certifies, to the best of his or her 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 an 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
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 instructions [as amended by
"Government wide Guidance for New Restrictions on Lobbying," 61 Fed. Reg. 1413 (1/19/96). Note:
Language in paragraph (2) herein has been modified in accordance with Section 10 of the Lobbying
Disclosure Act of 1995 (P.L. 104-65, to be codified at 2 U.S.C. 1601, ef seq.)]
(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 31, U.S.C. § 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.
[Note: Pursuant to 31 U.S.C. § 1352(c)(1)-(2)(A), any person who makes a prohibited expenditure or fails to
file or amend a required certification or disclosure form shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such expenditure or failure.]
The Seller certifies or affirms the truthfulness and accuracy of each statement of its certification and
disclosure, if any. In addition, the Seller understands and agrees that the provisions of 31 U.S.C. A 3801, ez
seq., apply to this certification and disclosure, if any.
Executed this day of ,20__
Name of Bidder Address
City/State/Zip
Name of Contractor's Authorized Official Signature of Contractor's Authorized Official, Title
