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<br />CERIlEJCATION REGARDING LQ&Jilltill <br /> <br /> <br />The undersigned certifies, to the best of his or her knowledge and belief that: <br /> <br />(1) 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 an <br />employee of any agency, 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 <br />entering into of any cooperative agreement, and the extension, continuation, renewal, <br />amendment, or modification of any federal contract, grant, loan, or cooperative <br />agreement. <br /> <br />(2) If any funds other than federal appropriated funds have been paid or will be paid to any <br />person for influencing or attempting to influence an officer or employee of any agency, <br />a member of congress, an officer or employee of congress, or an employee of a member <br />of congress in connection with this federal contract, grant, loan, or cooperative agreement, <br />the undersigned shall complete and submit Standard Form-111, "Disclosure Form to <br />Report Lobbying," in accordance with its instructions. <br /> <br />(3) The undersigned shall require that the language of this certification be included in the <br />award documents for all subawards at all tiers (including subcontracts, subgrants, and <br />contracts under grants, loans and cooperative agreements) and that all subrecipients shall <br />certify and disclose accordingly. <br /> <br />This certification is a material representation of fact upon which reliance was placed when this transaction <br />was made or entered into. Submission of this certification is a prerequisite for making or entering into this <br />transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required <br />certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each <br />such failure. <br /> <br /> <br />r2/1- ~ '( <br /> <br />Date. <br /> <br />Y BETHEL, ADMINISTRATOR <br />Print Name of Authorized Individual <br /> <br />756002206799-0l <br />Application or Contract Number <br /> <br />,EARlS.:L.AMAR COUNTY HEALTH DEPAETMEm <br />Organization Name <br /> <br />p. O. BOX 938 <br />EARlS, rX 75460-0938 <br />