NC DOT 5310 FY14 delegation and lobbying certification(Authorized Official's Typed/Printed Name)
as the designated party for
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1' 1 a,
(Authorized
(Grant Recipient/Applicant Agency)
with authority to submit funding applications and enter into contracts with the Department of Transportation and
execute all agreements and contracts with the North Carolina Department of Transportation, Public Transportation
Division, hereby delegate authority to the individual(s) filling the positions as indicated below:
Primary Designee:
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(Name & Primary Designee's Position Title)
(Primary Designee's Agency)
Reimbursement Requests: Yes ❑ No
Budget Revisions: [•]Yes ❑ No
Budget Amendments: 21Yes ❑ No
Period of Performance Extensions: 2Yes ❑ No
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Alternate Designee: Lt SCE �_� 1 "��1L��lC �r1 , �l G� k i se C4 ()F ,
(optional) �ano�er (Name Alternate Designee's Position Title)
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(Alternate Designee's Agency)
Reimbursement Requests: 211y-es ❑ No
Budget Revisions: []1Yes ❑ No
Budget Amendments: [Yes ❑ No
Period of Performance Extensions: Yes No
Authorized Official's Si
Authorized Official's Typed/Printed Name:
Please submit to: NCDOT/PTD
Attn: Charlie Wright
1550 Mail Service Center
Raleigh, NC 27699 -1550
Date:
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Attachment B
Certif cation Regarding Lobbying
(for bids and/or awards of $100,000 or more)
The Contractor 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 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 Form -LLL, "Disclosure Form to Report
Lobbying," in accordance with its instructions.
(3) The Contractor 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.
Title: Vw t S
Updated 09/22/11 Page 40 of 40