ORANGE COUNTY, MENTAL HEALTH ASSOCIATION OF (2)

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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 MP.P. rpvgr9zcl fr%r ni iklin hr irri— rli-1-- 1 1. Type of Federal Action: 2. Status of Federal Action: V~ 3. Report Type: a. contract Ela. bld/offer/application a. initial filing El b. grant b. initial award b. material change c. cooperative agreement c. post -award For Material Change Only: d. loan year ____---- -- quarter ___-- e, loan guarantee --- date of last report -------- L loan insurance • • ----- 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name ❑ Prime ❑ 5ubawardee and Address of Prime: Tier -----, if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: ---------- -- 8. Federal Action Number, if known: 9. Award Amount, if known: 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. IOa) ( last name, first name, MI ): (attach Continuation Sheet(s) SF-LLLA, ifnecessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): _❑ actual ❑ planned ❑ a. retainer ❑ b. one-time fee ❑ c. commission 12. Form of Payment (check all that apply): ❑ a. cash [] d. contingent fee ❑ b. in -kind; specify: nature ---------- ❑ e, deferred value ❑ f. other- specify: 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheets) SF-LLLA, lfnecessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16, Information requested Through this form Is authorized by title 31 U.S.C, section 135Z This disclosure of lobbying activities Is a materiel representation of fad Signature: upon which reliance was placed by the tier abovewhan this transection was made or entered Into. This disclosure Is required pursuent to 31 U.S.C. 1352. This print Name: Information will be reported to the Congress semi-annualy and will be available for Inspection. Any Title: public person who falls to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100.000 for - eachsud,failure. Telephone No.: Date: Authorized for LocalReproduction Standard Form LLL (Rev. 7-97)