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S:\GLarson\WORD\PSA Survey 2005-2006.doc <br /> 0 <br /> Exhibit D-3 <br /> Certification Regarding The Restrictions of The use of Federal Funds for <br /> Lobbying <br /> The prospective participant certifies,by signing and submitting this bid or proposal,to the best of his or <br /> her 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 <br /> any person for influencing or attempting to influence an officer or employee of any federal agency, a <br /> member of Congress,an officer or employee of Congress,or an employee of a member of Congress in <br /> connection with the awarding of any federal contract,the making of any federal grant,the making of any <br /> federal loan,the entering into of any cooperative agreement,and the extension,continuation,renewal, <br /> amendment, or modification of any federal 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 <br /> influencing or attempting to influence an officer or employee of any federal agency, a member of <br /> Congress, an officer or employee of Congress,or an employee of a member of Congress in connection <br /> with this federal contract,grant, loan, or cooperative agreement,the undersigned shall complete and <br /> submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. <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 shall 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 prospective participant also agrees by submitting his or her bid or proposal that he or she shall <br /> require that the language of this certification be included in all lower tier subcontracts which exceed <br /> $100,000 and that all such subrecipients shall certify and disclose accordingly. <br /> Consultant: (Firm): <br /> Date Signature <br /> 1 9 <br />