ac-Certification of Payments to Influence Federal Transactions

OMB Approval No. 2577-0157 (Exp. 1/31/2027) 
U.S. Department of Housing
and Urban Development
Certification of Payments 
to Influence Federal Transactions 
Office of Public and Indian Housing
Applicant Name
Program/Activity Receiving Federal Grant Funding
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be
(3) The undersigned shall require that the language of this
paid, by or on behalf of the undersigned, to any person for
certification be included in the award documents for all subawards
influencing or attempting to influence an officer or employee of
at all tiers (including subcontracts, subgrants, and contracts
an agency, a Member of Congress, an officer or employee of
under grants, loans, and cooperative agreements) and that all
Congress, or an employee of a Member of Congress in connec-
sub recipients shall certify and disclose accordingly.
tion with the awarding of any Federal contract, the making of any
This certification is a material representation of fact upon which
Federal grant, the making of any Federal loan, the entering into
reliance was placed when this transaction was made or entered
of any cooperative agreement, and the extension, continuation,
into. Submission of this certification is a prerequisite for making
renewal, amendment, or modification of any Federal contract,
or entering into this transaction imposed by Section 1352, Title
grant, loan, or cooperative agreement.
31, U.S. Code. Any person who fails to file the required
certification shall be subject to a civil penalty of not less than
(2) If any funds other than Federal appropriated funds have
$10,000 and not more than $100,000 for each such failure.
been paid or will be paid 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 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.
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010,
1012; 31 U.S.C. 3729, 3802)
Name of Authorized Official 
Title
Signature 
Date (mm/dd/yyyy)
Previous edition is obsolete 
form HUD 50071 (01/14) 
Public reporting burden for this information collection is estimated to average 30 minutes,including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and  
completing and reviewing the collection of information.  The information  requested is required to obtain a benefit.  This form is used to ensure federal funds are not used to influence members of Congress.  There are no  
assurances of confidentiality.   HUD may not conduct or sponsor, and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Comments regarding  
the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, Office of Policy Development and Research, REE, Department of Housing and Urban Development, 451 7th St SW,  
Room 4176, Washington, DC 20410-5000.  When providing comments, please refer to OMB Approval No. 2577-0157. 
CITY OF CHANDLER HOUSING AND REDEVELOPMENT
LOW RENT PUBLIC HOUSING 
Mayor Kevin Hartke
Chairman