2-Clark Attach 6 Lobbying.pdf

ATTACHMENT #6

ADOT LOBBYING CERTI FICATE

Procurement

ARIZONA DEPARTMENT OF TRANSPORTATION

LOBBYING CERTIFICATI ON

CERTIFICAT!ON FOR FEDERAL AID CONTRACTS

Applies to: Federal-aid contractors, and consultants, as well as lower tier sub-contractors and sub-consultants

The prospective participant certifies, by signing and submitting this bid or proposal, 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 Federal 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, amendrnent, or modification of any Federal contract, grant, Ioan, or cooperative agreement.

(2) lf 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 Federal 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.

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 510,000 and not more than 5100,000 for each such failure.

The prospective porticipont olso ogrees by submitting his or her bid or proposol thot he or she sholl require thot the languoge of this certiticotion be included in oll lower tier subcontrocts, which exceed 5700,000, ond thot oll such sub recipients sholl certify and disclose occordingly.

l'4

1.Ol20/2023

SIGNATURE DATE

President

TITLE

Available online at https://app.az.sovl SOLICITATION NO: BPM005710 Page 1 of

Rev.09/2022

Procurement

DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.c. 1352

(See next page for public burden disclosure.)

I ofFederal Action:

a. Contract

b. Grant

c. Cooperativeagreement

d. Loan

e. loan guarantee

f. loan insurance

2. Status ofFederal Action:

a. bid/offer/application

b. initial award

c. post-award

J. tlpe:

a. initial filing

b. material ohange

For Material Change Only:

year quarter date of lust .epoi-

4. Name and Address of Reporting Entity:

E Prime ! Subawardee

Congressional Dislrict, i/ known

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

Congressional District, if known

6. Federal Department Agency: 7. Federal Program Name/Description:

CDFA Number, d applicable:

8. Federal Action Number, if known: 9. AwardAmount, if known

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

b. Individuals Performing Services (including address if dffirentfrom No. 10a) (ast name, first name, MI):

1 1 . Amount of Payment (check all that apply):

$ E actual I planned

13. Type of Payment (check all that apply)

Ea.

trb.

Ec.

Eo.

Ee.

nr.

retainer one-time fee commission contingent fee defered other, specifu

12. Form of Payment (check all that app|:

! a. cash

E U. ln-tind; specifl nature value

14. Brief Description of Services Performed or to be Pefiormed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment indicated in ltem 11:

NONE

( atla<:lt Co ntinu at b n S lte et ( s ) S F- L LL-A, if nec e ssa ry )

15. Contiruations Sheet(s) SF-LLL-A attached I Yes X No

I 6, lnformtion requestcd through this fom is authorized by title 3l U..S.C. section 1352. This disclosure of lobbying activitics is a mterial represcntation of fact upon which reliance was placed by the ties above when this tmnsaction was made or entcrcd into. This disclosu'e is required pursunt to 31 U.S.C. 1352. This information will be reporled to the Congress semi-amually and will be available for public inspection. Any person who fails to frle the rcquircd disclosurrc shall be subject to a civil penalty of not less than $ 1 0,000 and trot morc than $ I 00,000 for cach such failure, Signature:

Print Name:

Title:

Telephone No. Date:

Federal Use Only Authorized for Local Reproduction Standard Fom - LLL

Available online at https://a pp.a z.gov/ SOLICITATION NO: 8PM005710 Page 2 of

Rev. 09/2022 t\tr oT ATTACHMENT #6

Procurement

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. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate.

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. ldentify 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. ldentify the status of the covered Federal action.

3. ldentifytheappropriateclassificationofthisreport.Thisisafollow-upreportcausedbyamaterial changetotheinformationpreviouslyreported,entertheyearand quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entlty for this covered Federal action.

entity that designates if it is, or expects to be, a prime or subaward recipient. ldentify 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. lf 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. lnclude

Congressional District, if known.

6. Enter the name of the Federal agenry making the award or loan commitment. lnclude 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). lf known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, bans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in hem 1 (e.g., Request for Proposal (RFP) number; lnvitation for Bid

(lFB) number; grant announcement number; the contract, grant, or ban award number; the application/proposal control number assigned by the Federal agency). lnclude prefixes, e.g., "RFP-DE-90-001".

9. 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.

10. (a) Enterthefull name,address,city,stateandzipcodeofthelobbyingentityengagedbythereportingentityidentifiedinhem4toinfluencethe Federal action.

covered

(b) Enter the full names of the individual(s) perform ing services, a nd include full add ress if different from 10 (a). Enter Last Name, First Name, and M iddle lnitial (M l).

11. Entertheamountofcompensationpaidorreasonablyexpectedtobepaidbythereportingentity(item4)tothelobbyingentity(item10),lndicatewhetherthepayment has been made (actual) or will be made (planned). Check all boxes that apply. lf this is a material change report, enter the cumulative amount of payment made or planned to be made.

12. Checktheappropriatebox(es).Checkallboxesthatapply.lfpaymentismadethroughanin-kindcontribution,specifythenatureandvalueofthein-kind payment.

13. Checktheappropriatebox(es).Checkallboxesthatapply.lfother,specifynature.

14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered.

lnclude all preparatory and related activity, not just time spent in actual contact with Federal officials. ldentify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or Member(s) of Congress that were contacted.

15. Check whether or not a SF-LLL-A Continuation Sheet (s) is attached.

16. The certifying official shall sign and date the form, print his/her name, title, and telephone number, sources, gathering and maintaining the data needed, and completing and reviewing the coltection 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"046), Washington, D.C. 20503.

Available online at httpsi/lapp.az.eovl SOLICITATION NO: BPM005710 Page 3 of

Procurement

DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Reporting Entity: of

Page

ECS - Form 90-3

Available online at https://app.az.g,ovl SOLICITATION NO: 8PM005710 Page 4 of