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(Required of all Applicants, except an Indian tribe or a tribal organization) <br /> CERTIFICATION AND RESTRICTIONS ON LOBBYING <br /> 1, Barry Jacobs , on behalf of <br /> Name of Authorized Official <br /> Orange County,North Carolina , <br /> Legal Name of Applicant <br /> Hereby certifies that: <br /> No Federal/State appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any <br /> person for influencing or attempting to influence an officer or employee of any Federal/State agency, a Member <br /> of Congress or State Legislature, an employee of a member of Congress or State Legislature, or an officer or <br /> employee of Congress or State Legislature in connection with the awarding of any Federal/State contract, the <br /> making of any Federal/State grant, the making of any Federal/State loan,the entering into of any cooperative <br /> agreement, and the extension, continuation,renewal, amendment, or modification of any Federal/State contract, <br /> grant, loan, or cooperative agreement. <br /> If any funds other than Federal/State appropriated funds have been paid or will be paid to any person <br /> influencing or attempting to influence an officer or employee of any Federal/State agency, a Member of <br /> Congress or State Legislature, an employee of a member of Congress or State Legislature, or an officer or <br /> employee of Congress or State Legislature in connection with the Federal/State contract, grant, loan, or <br /> cooperative agreement,the undersigned shall complete and submit Standard Form—LLL, "Disclosure Form to <br /> Report Lobbying,"in accordance with its instructions. <br /> The undersigned shall require that the language of this certification be included in the award documents for all <br /> sub-awards at all tiers (including sub-contracts, sub-grants and contracts under grants, loans, and cooperative <br /> agreements) and that all sub-recipients shall certify and disclose accordingly. <br /> This certification is a material representation of fact upon which reliance was placed when this transaction was <br /> made or entered into. Submission of this certification is a prerequisite for making or entering into this <br /> transaction imposed by 31 U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person <br /> who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not <br /> more than $100,000 for each such failure. <br /> The undersigned certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on <br /> or with this certification and understands that the provisions of 31 U.S.C. Section 3801, et seq., are applicable <br /> thereto. <br /> i <br /> a ............................................................................................. <br /> Signature ofAuthorize dffici.l Affix Notary Seal Here <br /> i <br /> Seal Subscribed and-swan to a date) , DN3 � �� <br /> ary u6Ic => N01`gRY N= <br /> k W= <br /> o� PUBLIC G <br /> Printed Name and_,sadress <br /> My commission expires (date) `�� rt�cici©U��' <br /> .................................. .. ....... ......... ......... ........ <br /> I <br /> I <br /> 43 <br />