cooperative agreement, it will complete and submit Standard Form-LLL, "Disclosure
Form to Report Lobbying," in accordance with its instructions; and
It will require that the following language of be included in the award documents for all
sub awards at all tiers (including subcontracts, sub grants, and contracts under grants,
loans, and cooperative agreement(s) and that all Contractor(s) shall certify and
disclose accordingly as follows:
Lobbying Certification - 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.
Religious Organization — Pursuant to 24 CFR §5.109, the Contractor agrees that
funds provided under this Agreement will not be used to support or engage in
any explicitly religious activities, or in any other manner prohibited by law.
Contractor certifies is has not been federally debarred, suspended, or proposed for
debarment or otherwise excluded from receiving federal contracts.
OWNER (signature) Nashua Glass (signature)
James W. Donchess, Mayor
(Printed Name and Title) (Printed Name and Title)
Date
Date
AG-12
