Header and burden statement
OMB Number 2900-0559, an expiration date of Oct. 31, 2026, a respondent burden of 15 minutes, and a note naming 38 U.S.C. 2408 as the statutory authority for a State Cemetery Grant.
VA40-0895-9
Certification Regarding Lobbying
- Agency
- VA
- Revision
- September 2023
- Fillable fields
- 4
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form VA40-0895-9: Certification Regarding Lobbying
VA Form VA40-0895-9 is the U.S. Department of Veterans Affairs Certification Regarding Lobbying. The form says the information is necessary to ensure that the State, Tribal or eligible County 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. It names 38 U.S.C. 2408 as the statutory authority for a State Cemetery Grant.
It is a one-page grant certification signed by a government official, not a Veteran benefit form. It is made in compliance with Section 319 of Public Law 101-121 and covers contracts, grants, loans and cooperative agreements. The certifying official agrees to three statements, then signs and gives a name, title, project FAI number and the agency's name and address.
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What's on VA Form VA40-0895-9
Statement (1): appropriated funds
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 agency officer or employee or Congress in connection with a Federal contract, grant, loan or cooperative agreement.
Statement (2): other funds
If any other funds have been paid or will be paid for influencing in connection with the transaction, the undersigned completes and submits Standard Forms-LLL in accordance with its instructions.
Statement (3): subawards
The certification language is included in the award documents for all subawards at all tiers, including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements.
Penalty paragraph
Submission is a prerequisite imposed by section 1352, title 31 U.S. Code. The form says 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 and identification
Signature and date (mm/dd/yyyy), the certifying official's name and title, the project FAI (Federal Identification Number) number, and the name and address of the government agency.
How to complete VA Form VA40-0895-9
- 1
Read the three statements
The undersigned certifies to the best of their knowledge and belief to statements (1) to (3).
- 2
Check for other lobbying payments
Where funds other than Federal appropriated funds were or will be paid for influencing, statement (2) points to Standard Forms-LLL, Disclosure Form to Report Lobbying.
- 3
Carry the language into subawards
Statement (3) says the certification language is included in the award documents for all subawards at all tiers.
- 4
Sign and date it
The State, Tribal or eligible County government certifying official signs and enters the date.
- 5
Fill in the identification fields
Enter the certifying official's name and title, the project FAI number, and the name and address of the government agency.
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Where it goes and edition
With the transaction
The form says submission of this certification is a prerequisite for making or entering into this transaction. It does not print a mailing address.
Not to the burden address
Comments on the burden estimate go to OIRA Desk Officer for VA, 725 17th St NW, Washington, DC 20503. The form says to send comments only and not applications for a grant to this address.
Edition
The footer reads VA FORM SEP 2023. It carries OMB Number 2900-0559, with an expiration date of Oct. 31, 2026.
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Who completes VA Form VA40-0895-9?
The form names the government, its certifying official and the subrecipients it reaches.
Official sources and the blank
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Questions about Form VA40-0895-9
What is VA Form VA40-0895-9 used for?
The form says the information is necessary to ensure that the State, Tribal or eligible County government has complied with Public Law 101-121 regarding payments to influence an officer or Member of Congress in connection with the award of a grant.
What is Standard Form LLL?
The form names Standard Forms-LLL, Disclosure Form to Report Lobbying. Statement (2) says the undersigned completes and submits it if funds other than Federal appropriated funds were or will be paid for influencing in connection with the transaction.
What penalty does the form state?
It says 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.
Does the certification apply to subawards?
Statement (3) says the language is included in the award documents for all subawards at all tiers and that all subrecipients certify and disclose accordingly.
Which laws does the form cite?
Section 319 of Public Law 101-121, the Interim Final guidance published on December 20, 1989 in the Federal Register (Pages 52306-52332), and section 1352, title 31 U.S. Code.
How long does it take to complete?
The form estimates the public reporting burden at an average of 15 minutes.