Fillable Printable VA Form 40-0895-9

VA Form 40-0895-9

OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION REGARDING LOBBYING

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory

authority for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal

government has complied with Public Law 101-121 regarding the prohibition against any payments to anyone that influences or

attempts to influence an officer or Member of Congress in connection with the award of a grant. VA may not conduct or sponsor and

you are not required to respond to this collection of information unless it displays a valid OMB number. Respond to this collection is

voluntary. Send comments regarding the burden estimate or any other aspects of this collection of information, including suggestions

for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW, Washington, DC 20420. SEND

COMMENTS ONLY. Please do not send applications for a grant to this address.

This certification is made in compliance with Section 319 of Public Law 101-121 and pursuant to the Interim Final guidance published

on December 20, 1989 in the Federal Register (Pages 52306-52332).

Certification for Contracts, Grants, Loans, and Cooperative Agreements.

The undersigned certifies, to the best of their 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 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 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 Forms-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.

SIGNATURE OF STATE OR TRIBAL GOVERNMENT CERTIFYING OFFICIALDATE (mm/dd/yyyy)

NAME OF STATE OR TRIBAL GOVENMENT

CERTIFYING OFFICIAL

TITLE OF STATE OR TRIBAL GOVERNMENT CERTIFYING OFFICIAL

PROJECT FAI (Federal Identification

Number) NO.

NAME AND ADDRESS OF STATE OR TRIBAL GOVERNMENT AGENCY

VA FORM

OCT 2010

40-0895-9