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CSRTWICASIOA REGARDING LOBRTMffG <br />L � . <br />K1] <br />The undersigned cartUlm, to the bmt af I& ar bar knowledge and belief, <br />that: <br />(i) No Federal apprmn lated funds haw been paid ar wM be paid, by or an <br />influence an ar empkwee of any agency, a member of Congress, an <br />ccffl ar employee of Congress, or an employee af a member of Congress in <br />c=necth= vtth the awardtag of any Federal contract, the mak:inq of any <br />Federal grant, the k•■ g of any Pedual loan, the .=tc . .. ■• Of _ • <br />coope.Latty agreement, and the extension, continuabon, renewal, amemdment, or <br />modifeabon of any Federal contract, grant, loan, or --- attwe agreement. <br />(2) If any funds other than Federal appropriated ft: <br />be paid to any person for Influencing or attapting ' <br />employee of any agency, a Member of Congress, an i <br />Congress, or an employee of a Member of Congress i <br />Contract, grant, loan, or coopexalive agrument, the <br />and submit StLudar perm -.LLL, •Diwlom= Farm to <br />■ <br />.r,ds have be= paid or wM <br />rr, . i ■ u.. an . r. Wer or <br />.r ar employee of <br />necdork wtth the Federal <br />undersigned sball complete <br />Rep= • • • ■ • <br />• I. To } _r M 1 • .. _1 • .■ _ rJ .•. . • . <br />Placed when ■• • r.._. v made or a. ro r. Into. • •1 ■ max... of this <br />carttBicadel" making or enterIng into thds transaction <br />imposed by section, =%, tMe 31, U.S. Code. Any person wbo faJIs to Me the <br />0_.r_u=ed a my fx=5on shaM be subject to a d�vn penalty of not less than <br />S10,000 and not mcre than S100,000 fw each such bul=*- <br />e Calm Health RMEtment <br />(Name cc ) <br />