Laserfiche WebLink
Page 2 of 2 <br />REVISED - FORM 4.05 CERTIFICATION REGARDING LOBBYING BY CONTRACTOR <br />Pursuant to 45 CFR Part 93.110 (which is by this reference incorporated herein), the undersigned <br />certifies, to the best of his or her knowledge and belief, that: <br />A.No Federal appropriated funds have been paid or will be paid, by or on behalf of the <br />undersigned, to any person for influencing or attempting to influence an officer or employee of <br />an agency, a Member of Congress, an officer or employee of Congress, or an employee of a <br />Member of Congress in connection with the awarding of any Federal contract, the making of any <br />Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, <br />and the extension, continuation, renewal, amendment, or modification of any Federal contract, <br />grant, loan, or cooperative agreement. <br />B.If any funds other than Federal appropriated funds have been paid or will be paid to any person <br />for influencing or attempting to influence an officer or employee of any agency, a Member of <br />Congress, an officer or employee of Congress, or an employee of a Member of Congress in <br />connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned <br />must complete and submit Standard Form-LLL Disclosure Form to Report Lobbying, in accordance <br />with its instructions. <br />C.The undersigned must require that the language of this certification be included in the award <br />documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under <br />grants, loans, and cooperative agreements) and that all subrecipients must certify and disclose <br />accordingly. <br />This certification is a material representation of fact upon which reliance was placed when this <br />transaction was made or entered into. Submission of this certification is a prerequisite for making or <br />entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file <br />the required certification must be subject to a civil penalty of not less than $10,000 and not more than <br />$100,000 for each such failure. <br />The Contractor, ___________________, certifies or affirms the truthfulness and accuracy of each <br />statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees <br />that the provisions of 31 U.S.C. A 3801, et seq., apply to this certification and disclosure, if any. <br />____________________________ <br />Signature of Contractor <br />____________________________ <br />Print Name <br />____________________________ <br />Title <br />_____________________________ <br />Date <br />_____________________________ <br />Address <br />_____________________________ <br />City, State, ZIP <br />NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.