SFLLL Certification Regarding Lobbying

CERTIFICATION REGARDING LOBBYING
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 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
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 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 of all sub-awards at all tiers (including subcontracts, sub-grants,
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, United States 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.

Organization:
Street address:
City, State, Zip:

CERTIFIED BY:(type or print)
TITLE:

(signature)

(date)

Approved by OMB
0348-0046
Disclosure of Lobbying Activities
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for public burden disclosure)
1.

Type of Federal Action:
a. contract
____ b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance

4.

2.

Status of Federal Action:
a. bid/offer/application
_____ b. initial award
c. post-award

Name and Address of Reporting Entity:
____ Prime
_____ Subawardee
Tier______, if Known:

Congressional District, if known:
6. Federal Department/Agency:

3.

Report Type:
a. initial filing
_____ b. material change

For material change only:
Year _______ quarter _______
Date of last report___________
5.

If Reporting Entity in No. 4 is Subawardee, Enter
Name and Address of Prime:

Congressional District, if known:
7. Federal Program Name/Description:

CFDA Number, if applicable: __________________
8. Federal Action Number, if known:

9. Award Amount, if known:

10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, MI):

$
b. Individuals Performing Services (including address if
different from No. 10a)
(last name, first name, MI):

11. Information requested through this form is
authorized by title 31 U.S.C. section 1352. This
disclosure of lobbying activities is a material
representation of fact upon which reliance was placed
by the tier above when this transaction was made or
entered into. This disclosure is required pursuant to 31
U.S.C. 1352. This information will be reported to the
Congress semi-annually and will be available for public
inspection. Any person who fails to file the required
disclosure shall be subject to a civil penalty of not less
than $10,000 and not more than $100,000 for each such
failure.
Federal Use Only

Signature: __________________________________
Print Name:_________________________________
Title:______________________________________
Telephone No.: ________________ Date: _______

Authorized for Local Reproduction
Standard Form - LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at
the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31
U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any
lobbying entity 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 a
covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to
the implementing guidance published by the Office of Management and Budget for additional information .
1.

Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence
the outcome of a covered Federal action.

2.

Identify the status of the covered Federal action.

3.

Identify the appropriate classification of this report. If this is a followup report caused by a material change
to the information previously reported, enter the year and quarter in which the change occurred. Enter the
date of the last previously submitted report by this reporting entity for this covered Federal action.

4.

Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District,
if known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be,
a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is
the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under
grants.

5.

If the organization filing the report in item 4 checks “Subawardee,” then enter the full name, address, city,
State and zip code of the prime Federal recipient. Include Congressional District, if known.

6.

Enter the name of the federal agency making the award or loan commitment. Include at least one
organizational level below agency name, if known. For example, Department of Transportation, United
States Coast Guard.

7.

Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the
full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and
loan commitments.

8.

9.

10.

Enter the most appropriate Federal identifying number available for the Federal action identified in item 1
(e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number;
the contract, grant, or loan award number; the application/proposal control number assigned by the Federal
agency). Included prefixes, e.g., “RFP-DE-90-001.”
For a covered Federal action where there has been an award or loan commitment by the Federal agency,
enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5.
(a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying
Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal
action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from
10(a). Enter Last Name, First Name, and Middle Initial (MI).

11.

The certifying official shall sign and date the form, print his/her name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of
information unless it displays a valid OMB control Number. The valid OMB control number for this information
collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10
minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0046), Washington, DC 20503