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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 lmowledge 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 an employee of any agency, 3 <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 />an officer or employee of Congress, or an employee of a member of Congress in connection with this <br />federal contract, grant. loan, or cooperative agreement, the undersigned shall complete and submit <br />Standard Form LLL, "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 />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 that $10,000 and not more than $100,000 for each <br />such failure. • <br />Signature Date <br />Print Name of Authorized Individual <br />2009-028229 <br />Appiication or Contract Number <br />PARIS-LAMAR COUNTY HEALTH <br />DEPARTMENT <br />Organization Name <br />CSCU # EF29-12374 - Revised 08.10.07 <br />