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SECTION 00474 375-030-33 STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION. PROCUREMENT CERTIFICATION FOR DISCLOSURE OF LOBBYING ACTIVITIES Corot ON FEDERAL -AID CONTRACTS (Compliance with 49CFR, Section 20.100 (b)) The prospective participant certifies, by signing this certification, that to the best of his or her knowledge and belief: (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, 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 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 of Lobbying Activities", in accordance with its instructions. (Standard Form -LLL can be obtained from the Florida Department of Transportation's Professional Services Administrator or Procurement Office.) 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. The prospective participant also agrees by submitting his or her proposal that he or she shall require that the language of this certification be included in all lower tier subcontracts, which exceed $100,000 and that all such subrecipients shall certify and disclose accordingly. Name of Business fi N -S— (V % v By: _ Date: `ZA • V2 Authorized Signat Title: A0,14— 00474 -1 F:\PubI1cWorks\ENGINEERING DIVISION PROJECTS\1415-IR Blvd Sidewalk 37th St to 53rd St11-Adminlbid documents\LAP Documents\00474- CERTIFICATION for DISCLOSURE OF LOBBYING ACTIVITIES.doc