APPENDIX M - LOBBYING RESTRICTION FORM CD-512.pdf

FORM CD-512 U.S. DEPARTMENT OF COMMERC E

(REV 05-17)

CERTIFICATION REGARDING LOBBYING

LOWER TIER COVERED TRANSACTIONS

Applicants should review the instructions for certification included in the regulations before completing this form. Signature on this form provides for compliance with certification requirements under 15 CFR Part 28, “New Restrictions on Lobbying.”

LOBBYING Statement for Loan Guarantees and Loan Insurance As required by Section 1352, Title 31 of the U.S. Code, and The undersigned states, to the best of his or her knowledge implemented at 15 CFR Part 28, for persons entering into a grant, and belief, that:

cooperative agreement or contract over $100,000 or a loan or loan guarantee over $150,000 as defined at 15 CFR Part 28, Sections In any funds have been paid or will be paid to any person for

28.105 and 28.110, the applicant certifies that to the best of his or her influencing or attempting to influence an officer or employee knowledge and belief, that: of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in

(1) No Federal appropriated funds have been paid or will be paid, connection with this commitment providing for the United by or on behalf of the undersigned, to any person for influencing or States to insure or guarantee a loan, the undersigned shall attempting to influence an officer or employee of any agency, a complete and submit Standard Form-LLL, ‘‘Disclosure Form Member of Congress in conncection with the awarding of any to Report Lobbying,’’ in accordance with its instructions.

Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, Submission of this statement is a prerequisite for making or and the extension, continuation, renewal, amendment, or entering into this transaction imposed by section 1352, title modification of any Federal contract, grant, loan, or cooperative 31, U.S. Code. Any person who fails to file the required state-agreement. ment shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure occurring

(2) If any funds other than Federal appropriated funds have been on or before October 23, 1996, and of not less than $11,000 paid or will be paid to any person for influencing or attempting to and not more than $110,000 for each such failure occurring influence an officer or employee of any agency, a Member of after October 23, 1996.

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.

(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, 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, 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 occurring on or before October 23, 1996, and of not less than $11,000 and not more than $110,000 for each such failure occurring after October 23, 1996.

As the duly authorized representative of the applicant, I hereby certify that the applicant will comply with the above applicable certification.

NAME OF APPLICANT AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE