DISCLOSURE OF LOBBYING ACTIVITIES
The undersigned [Contractor] certifies, to the best of his or her knowledge and belief, that:
(1)
(2)
(3)
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.
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 Cangress 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 fas
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, et seg.}]
The undersigned shall require that the language of this certification be included in the award
documents for ail subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shail 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 34, 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 Sellercertifies or affirms the truthfulness and accuracy of each statement of its certification and
disclosure, if any. In addition, the Sellerunderstands and agrees that the provisions of 31 U.S.C. A 3801,
et seq., apply to this certification and disclosure, if any.
Executed this. day of. ,20__
Name of Bidder Address
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Name of Contractor's Authorized Official $
gnature of Contractor's Authorized Official Title
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of Contractor's Authorized Official
