Rucker Avenue Chiropractic Center P.S. 1/18/2022

Exhibit 5: LOBBYING CERTIFICATION FORM The undersigned certifies,to the best of the undersigned's 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 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 Form-LLL,"Disclosure Form to Report Lobbying,"in accordance with its instructions,as attached. (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. I hereby certify that I have read the above certification,and that the information and my statements provided herein by me are true and correct to the best of my knowledge,and by my signature on this document,acknowledge my understanding that any intentional or negligent misrepresentation or falsification of any of the information in this document could subject me to punishment under federal and/or civil liability and/or in criminal penalties,including but not limited to fine or imprisonment or both under Title 18,United States Code,Sec.1001,et seq.and punishment under federal law. Leland Patron Printed Name Si President 12/23/2021 Title Date EVERETT ��'`�� '" Everett FOrWilfll GIJiII I'Ioki ni"i<'omo11l l 1 WASHINGTON