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<br />Everett Forward Grant Program | Agreement | Page 13 <br />Exhibit 5: LOBBYING CERTIFICATION FORM <br />The undersigned certifies, to the best of the undersigned’s knowledge and belief, that: <br />(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any <br />person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an <br />officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any <br />Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any <br />cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal <br />contract, grant, loan, or cooperative agreement. <br />(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing <br />or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee <br />of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or <br />cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to <br />Report Lobbying,” in accordance with its instructions, as attached. <br />(3) The undersigned shall require that the language of this certification be included in the award documents for all <br />subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative <br />agreements) and that all subrecipients shall certify and disclose accordingly. <br />This certification is a material representation of fact upon which reliance was placed when this transaction was <br />made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction <br />imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject <br />to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. <br />I hereby certify that I have read the above certification, and that the information and my statements provided herein <br />by me are true and correct to the best of my knowledge, and by my signature on this document, acknowledge my <br />understanding that any intentional or negligent misrepresentation or falsification of any of the information in this <br />document could subject me to punishment under federal and/or civil liability and/or in criminal penalties, including <br />but not limited to fine or imprisonment or both under Title 18, United States Code, Sec. 1001, et seq. and punishment <br />under federal law. <br /> <br />_____________________________ ______________________________ <br />Printed Name Signature <br /> <br />_____________________________ ______________________________ <br />Title Date <br /> <br /> <br /> <br />Tami Agassi <br />07/22/2024