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8/04 <br />Certification Regarding Lobbying <br />Certification for Contracts, Grants, Loans, and Cooperative Agreements <br />The undersigned certifies, to the best of 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 employee of <br />any agency, a Member of Congress, an officer or employee of Congress, or an employee of a <br />Member of Congress in connection with the awarding of any Federal contract, the makirig of any <br />cooperative agreement, and the extension, continuation, renewal, amendment, or modification of <br />any Federal contact, grant, loan or cooperative agreement. <br />(2) If any funds 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 agency, a <br />Member of Congress, an officer or employee of Congress, or an employee of a Member of <br />Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the <br />undersigned shall complete and submit Standard Form -LLL, "Disclosure Form to Report <br />Lobbying," in accordance with its instructions. <br />(3) The undersigned shall require that the language of this certification be included in the award <br />documents for all subawards at all tiers (including subcontract, subgrants, and contracts under <br />grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose <br />accordingly. <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 <br />making or entering into this transaction imposed by Section 1352, Title 31, U. S. Code. Any <br />person who fails to file the required certification shall be subject to a civil penalty of not less <br />than $10,000 and not more than $100,000 for each such failure. <br />Boys & Girls Club of Santa Ana <br />Grantee /Contactor Organization Program Title <br />of Certifying Officer Si ture Date <br />EXHBIT C <br />Page 1 of 2 <br />17 <br />