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TEXAS DEPARTMENT OF STATE HEALTH SERVICES <br />CERTIFICATION REGARDING LOBBYING <br />CERTIFICATION FOR CONTRACTS GRANTS LOANS AND COOPERATIVE <br />AGREEMENTS <br />The undersigned certifies, to the best of his or her I:nowledge and belief that: <br />(l j No federal appropriated funds have been paid or will be paid, by o r on behalf of the undersigned, to <br />any person for influencing or attempting to influence an officer or an employee of any 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 <br />any federal loan, the entering into of any cooperative agreement, and the extension, continuation, <br />renewal, 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 agency, a member of congress <br />federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit, an <br />officer or employee of congress, or an employee of a member of congress in connection with this <br />Standard Form-1 1, "Disclosure Form to Report Lobbying," in accordance with its instructions. <br />(3) The undersigned shall 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 grants, <br />loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. <br />Phis 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 that $10,000 and not more than $100,000 for each <br />such failure. <br />Signature <br />Date <br />Print Name of~Authorized Individual <br />2008-024591 <br />Application or Contract Number <br />PARIS-LAMAR COUNTY HEALTH <br />DEPARTMENT <br />Organization Name <br />CSCU # EF29-12374 -Revised 2/2006 <br />