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DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />DIVISION OF PUBLIC HEALTH <br />CERTIFICATION REGARDING LOBBYING <br />The undersigned certifies, to the best of his or her knowledge and belief, that: <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 <br />employee of any agency, a Member of Congress, an officer or employee of Congress, or <br />an employee of a Member of Congress in connection with the awarding of any Federal <br />contract, continuation, renewal, amendment, or modification of any Federal contract, <br />grant, loan, or cooperative agreement. <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, a <br />Member of Congress, an officer or employee of Congress, or an employee of a Member <br />of Congress in connection with this Federally funded contract, grant, loan, or cooperative <br />agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure <br />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 <br />award document for subawards at alI tiers (including subcontracts, subgrants, and <br />contracts under grants, loans, and cooperative agreements) who receive federal funds of <br />$100,000 or more 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 <br />transaction was made or entered into. Submission of this certification is a prerequisite for <br />making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any <br />person who fails to file the required certification shall be subject to a civil penalty of not less <br />than $10,000 and not more than $100,000 for each such failure. <br />Authorize Agency Official Signature <br />Hest, l 11~ ~~ ~ e~-I-or <br />Title <br />Official gency Name <br />(Signature should be same as Contract signature) <br />~ ~ <br />_ PLEASE ACCEPT AS ORIGINAL SIGNATURES <br />~~ <br />Date <br />DPH Lobby 1/02 <br />