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CITY OF SANTA ANA <br />RFP NO.: 22.096 <br />ON CALL BMERf3ENCY ASPHALT & PCC <br />NON-LO13BMG CERTIFICATION <br />The prospective participant certifies, by signing and submitting this bid or proposal, to the best of <br />his or her knowledge and belief, that: <br />(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the <br />undersigned, to any person for influencing or attempting to influence an officer or <br />employee of any Federal agency, a Member of Congress, an officer or employee of <br />Congress, or an employee of a Member of Congress in connection with the awarding of <br />any Federal contract, the making of any Federal grant, the malting of any Federal loan, the <br />entering into of any cooperative agreement, and the extension, continuation, renewal, <br />amendment, or modification of any Federal contract, grant, loan, or cooperative agreement, <br />(2) If any finds other than Federal appropriated funds have been paid or will be paid to any <br />person for influencing or attempting to influence an officer or employee of any Federal <br />agency, a Member of Congress, an officer or employee of Congress, or an employee of a <br />Member of Congress in connection with this Federal contract, grant, loan, or cooperative <br />agreement, the undersigned shall complete and submit Standard Foim-LLL, "Disclosure <br />of Lobbying Activities," in conformance with its instructions. <br />This certification is a material representation of fact upon which reliance was placed when this <br />transaction was made or entered into. Submission of this certification is a prerequisite for making <br />or entering into this transaction imposed by Section 1352, Title 31, U.S. Code, Any person who <br />fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and <br />not more than $100,000 for each such failure. <br />The prospective participant also agrees by submitting his or her bid or proposal that he or she shall <br />require that the language of this certification be included in all lower tier subcontracts, which <br />exceed $100,000 and at all sue sabrecipients shall certify and disclose accordingly. <br />Signed: <br />Title: <br />Firm: V, � CZ6 �100 <br />Date: o <br />Page 8 of 10 <br />