10-0388-9 Certification Regarding Lobbying

OMB Number: 2900-0661
Estimated Burden: 1 hour

CERTIFICATION REGARDING LOBBYING
PROJECT DESCRIPTION
PROJECT LOCATION

FAI NUMBER

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 57306-52332).
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.

CERTIFICATION - THE LAW PR0VIDES SEVERE PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION.
NAME OF AUTHORIZED STATE OFFICIAL

SIGNATURE

TITLE OF AUTHORIZED STATE OFFICIAL

DATE (mm/dd/yyyy)

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 this
Act. The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. We may not collect or sponsor and you are
not required to respond to, a collection unless it has a valid OMB Control Number. This collection of information is collected under the authority of 38 U.S. Code Sections
8133(a) and 8135(a). VA will use this information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to
meet VA requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will be unable to
authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to which you are entitled.
VA FORM
DEC 2010

10-0388-9

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