19-50071.pdf

OMB Approval No. 2577-0157 (Exp. 1/31/2027) U.S. Department of Housing and Urban DevelopmentCertification of Payments to Influence Federal Transactions Office of Public and Indian Housing

Applicant Name

Program/Activity Receiving Federal Grant Funding

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 (3) The undersigned shall require that the language of this paid, by or on behalf of the undersigned, to any person for certification be included in the award documents for all subawards influencing or attempting to influence an officer or employee of at all tiers (including subcontracts, subgrants, and contracts an agency, a Member of Congress, an officer or employee of under grants, loans, and cooperative agreements) and that all Congress, or an employee of a Member of Congress in connec- sub recipients shall certify and disclose accordingly.

tion with the awarding of any Federal contract, the making of any

This certification is a material representation of fact upon whichFederal grant, the making of any Federal loan, the entering into reliance was placed when this transaction was made or enteredof any cooperative agreement, and the extension, continuation, into. Submission of this certification is a prerequisite for makingrenewal, amendment, or modification of any Federal contract, or entering into this transaction imposed by Section 1352, Titlegrant, loan, or cooperative agreement.

31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than(2) If any funds other than Federal appropriated funds have $10,000 and not more than $100,000 for each such failure.been paid or will be paid 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 this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, Disclosure Form to Report Lobbying, in accordance with its instructions.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Name of Authorized Official Title

Signature Date (mm/dd/yyyy)

Previous edition is obsolete form HUD 50071 (01/14)

Public reporting burden for this information collection is estimated to average 30 minutes,including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The information requested is required to obtain a benefit. This form is used to ensure federal funds are not used to influence members of Congress. There are no assurances of confidentiality. HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, Office of Policy Development and Research, REE, Department of Housing and Urban Development, 451 7th St SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. 2577-0157.