This page was read by OCR. Text can misread numbers, dates or table columns. Check the PDF before quoting or interpreting it. Redacted areas remain redacted.
Certification of Payments
to Influence Federal Transactions
OMB Approval No. 2577-0157 (Exp. 1/31/2027)
U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing
Public reporting burden for this information collection is estimated to average 30 minutes,including the tinte for reviewing instructions, scarching existing daca sources, gethering and maintaining the data needed, end
completing and reviewing the collection of information, The inforznation. requested is recuired to obtain a benefit. This form is used to ensure federal fimds are not used to influence members of Congress. There are no
assurances of confidentiality, HUD may aot conduct er sponsor, and an applicant is aot required to respond to a collection af information urless it displays a curently valid OMB contol number. Commens regarding
the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, Ofice of Polizy Development and Resear, REE, Departent of Housing and Urhan Development, 451 7d Se SW.
Room 4175. Washington, DC 20410-5000. Whea groviding comments, please vefer ta OMB Approval No, 2577-0137.
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
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 connec-
tion 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.
(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 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.
(3) The undersigned shall require that the language of this
certification be included in the award documents for all subawards
at ail tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all
sub recipients 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.
Thereby 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)
Naine of Authorized Official
Tite
‘Signature
Date (mm/dd/yy)
Previous edifion is obsolete
form HUD 509071 (01/14)Jump to an indexed page (88 of 88)