5700-53 Lobbying and Litigation Certificate

United States

ENVIRONMENTAL PROTECTION AGENCY

OMB Control No. 2030-0020
Approval expires 04/30/2012

Washington, DC 20460

LOBBYING AND LITIGATION CERTIFICATION FOR GRANTS
AND COOPERATIVE AGREEMENTS*
INSTRUCTIONS:
*At project completion, complete this form pursuant to the 2001 Department of Veterans Affairs and Housing and Urban
Development, and Independent Appropriations Act, Public Law 106-377, Section 424 and 2000 Department of Veterans
Affairs and Housing and Urban Development, and Independent Appropriations Act, Public Law 106-74, Section 426 and
any other subsequent Appropriation Act requirements.
Please mail this form to your EPA Grant Specialist within 90 days of project completion. DO NOT send this information
to the Office of Management & Budget.
Assistance Agreement Number(s):
________________________________________
________________________________________
________________________________________
I hereby certify that none of these funds have been used to engage in the lobbying of the Federal
Government or in litigation against the United States unless authorized under existing law.
__________________________________________
Signature of the Chief Executive Officer

____________________________
Date

__________________________________________
Print Name
Burden Statement - The annual public reporting and record keeping burden for this collection of information is estimated to average 5 minutes per
respondent. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide
information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and
systems for the purposes of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing
information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to
a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the
information. An agency may not conduct or sponsor, and a person is not required to respond to , a collection of information unless it displays a
currently valid OMB control number. The OMB control numbers for EPA’s regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15.
Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated collection techniques to the Director, Regulatory Information Division, U.S.
Environmental Protection Agency, Ariel Rios Building, 1200 Pennsylvania Avenue, N.W., Mail Code 3213A, Washington, DC 20460; and to the
Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, N.W., Washington, DC 20503, Attention: Desk
Officer for EPA. Include the EPA ICR number and OMB control number in any correspondence.

EPA Form 5700-53 (Rev. 04/2012)