Dot F 2308-1 Certification Regarding Lobbying For Contracts, Grants,

OMB NO.: 2105-0555

EXPIRATION DATE: MM/DD/YYYY

CERTIFICATION REGARDING LOBBYING

FOR

CONTRACTS, GRANTS, LOANS, AND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her 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 an 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, or 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 Form - LLL, "Disclosure of Lobbying Activities" in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients 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 21, 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.

Name of Organization: _______________________________________________________

Address: ____________________________________________

City: __________________________________

State: _____________________

Zip Code: _________________

______________________________________

(Signature of Authorized Official)

______________________________________

(Title of Authorized Official)

__________________________

(Date)

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

A Federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB Control No. for this information collection is 2105-0555. The information requested on this form is being collected and disseminated by the U.S. Department of Transportation, Office of the Secretary as a courtesy to the public. Public burden reporting for this collection of information is estimated to be 15 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection are mandatory. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Office, US Department of Transportation, Office so Small and Disadvantaged Business Utilization, Financial Assistance Division, 1200 New Jersey Ave., S.E., 5^th Floor, W56-497, Washington, DC 20590.

PRIVACY ACT STATEMENT

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this application is solicited under the authority of Title 49 U.S.C. 332(b)(3)(4)(5) which authorizes DOT OSDBU to assist Disadvantage Business Enterprises and Small and Disadvantaged Business in acquiring access to working capital and to debt financing, in order to obtain transportation related contracts wholly or partially funded by DOT. Your request cannot be processed unless the data is complete. Disclosures of name and other personal identifiers are required for a benefit, as DOT requires an individual seeking assistance from DOT to provide with sufficient information for it to evaluate the risk of a loan application. In making loan guarantees pursuant to Title 49 U.S.C. 332(b)(3)(4)(5), DOT is required to have reasonable assurance that the loan is of sound value and will be repaid or that is in the best interest of the Government to grant the assistance required. Routine uses of records maintained in the system include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analyst provided by a financial expert contractor working for OSDBU; the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee; and recording in the Grant Information System. Disclosure of your Social Security Number (SSN) and/or date of birth (DOB) are optional. Refusal to furnish your SSN and/or DOB will not result in the denial of any right, benefit or privilege provided by law; however, failure to provide SSN and/or DOB may result in the delay of a response of the processing of your loan application or its rejection. Routine uses of your social security number include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analysis provided by a financial expert contractor working for OSDBU; and the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee.

DOT F 2308-1