Va Form 10-0144 - Certification Regarding Lobbying printable pdf download

OMB Number: 2900-0160

Estimated Burden: 5 minutes

CERTIFICATION REGARDING LOBBYING

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in

accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We

may not conduct or sponsor, and you are not required to respond to, a collection of information unless it

displays a valid OMB number. We anticipate that the time expended by all individuals who must complete

this form will average 5 minutes. This includes the time it will take to read instructions, gather the necessary

facts and fill out the form. Although completion of this form is required to obtain and retain this Federal

grant, failure to complete the form will have no impact on any other benefits to which you may be entitled.

This certification is made in compliance with Section 319 of Public Law 101-121; and pursuant to the

Interim Final guidance published as part VII of the December 20, 1989, Federal Register (Pages 57306

through 52332).

Certification for Contracts, Grants, Loans, and Cooperative Agreements

The undersigned certified, to the best of their knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to

any person for influencing or attempting to influence an officer or employee of any agency, a Member of

Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with

the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the

entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or

modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for

influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an

officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal

contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard

Forms-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award

documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans,

and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction

was made or entered into. Submission of this certification is a prerequisite for making or entering into this

transaction imposed by section 1352, title 31 U.S. Code. Any person who fails to file the required

certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each

such failure.

SIGNATURE OF CERTIFYING OFFICIAL

DATE

NAME AND TITLE OF CERTIFYING OFFICIAL

PROJECT (FAI NUMBER)

NAME AND ADDRESS OF STATE AGENCY

VA FORM

10-0144

EXISTING STOCK OF VA FORM 10-0144, DATED SEP 1999, WILL BE USED.

SEP 2006 (R)

Va Form 10-0144 - Certification Regarding Lobbying