ESBD_369546_1721764079900_HHS0014056v3 Exhibit H Certification Regarding Lobbying.pdf
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- Attached to
- HHS0014056v3 Breast pump contract for WIC
- Solicitation number
- HHS0014056v3
- Issued by
- Travis County, Austin City, Texas
About this file
This document is a Certification Regarding Lobbying related to a state and local contract opportunity issued by the Texas Health and Human Services Commission (HHSC) for a Breast Pump Contract for the Women, Infants, and Children (WIC) program. The contract will provide breast pumps, accessories, and technical support for the Texas WIC program. The certification requires the applicant organization to disclose any federal funds used to influence government officials in relation to this contract opportunity. The contract term and details about the procurement process are not included in this document.
The certification outlines requirements for the applicant to disclose lobbying activities, include the certification language in any subcontractor agreements, and be subject to civil penalties for failing to file the required disclosure statements. Pricing terms, set-asides, incumbent information, funding sources, and other salient commercial details are not provided in this certification document.
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Grants.gov Lobbying Form D:20061122134148- 05'00' D:20061122134148- 05'00' Certification for Contracts, Grants, Loans, and Cooperative Agreements
(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 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.
If any 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 commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ''Disclosure of Lobbying Activities,'' in accordance with its instructions. Submission of this statement 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 statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
* APPLICANT'S ORGANIZATION
* SIGNATURE:
* DATE:
* PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
Suffix:
Middle Name:
* Title:
* First Name:
* Last Name:
Prefix:
CERTIFICATION REGARDING LOBBYING
(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, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
The undersigned certifies, to the best of his or her knowledge and belief, that:
Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that:
| Mandatory: |
| Applicant's Organization: Enter the legal name of the organization that will undertake the assistance activity. This should normally be the name under which the organization has registered with the Business Partner Network.: |
| Prefix: Select the prefix (e.g., Mr., Mrs., Rev.) for the name of the Authorized Representative.: |
| Suffix: Select the suffix (e.g., Jr, Sr, PhD) for the name of the Authorized Representative.: |
| First Name: Enter the first (given) name of the Authorized Representative who is signing this form.: |
| Middle Name: Enter the middle name of the Authorized Representative.: |
| Title: Enter the title of the Authorized Representative who is signing this form.: |
| Last Name: Enter the last (family) name of the Authorized Representative signing this form.: |
| Signature: It is the organization's responsibility to assure that only properly authorized individuals sign in this capacity and/or submit the application to Grants.gov. Enter the Signature of Authorized Representative.: |
| Date Signed: Enter the date the AOR signed the application.: |
| XDPFirstField: |
| LastField: |
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