COUNTY OF ORANGE (2) - 2004 - Laserfiche WebLink

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EXHIBIT H Page 2 of3 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose activities pursuant to 31 U.S.C 1352 (See reverse for public burden disclosure) 1. Type of Federal Actions: 2. Status of Federal Actions: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award d.loan For Material Change Only: e. loan guarantee Year Quarter f. loan insurance Date of I 4. Name and Address of Reporting Entity: 5. If Reporting Entity in NO.4 is a Subawardee. Prime Subawardee Enter Name and Address of Prime: Tier :if known: Congressional District, if known: Conoressional District, if known: 6. Federal Department / Agency: 7. Federal Program Name/Description: I CFDA Number. if known: 8. Federal Action Number, if known: g, Award Amount, if known: $ 1 Oa. Name and Address of Lobbying Entity 10b.lndividual Performing Services (if individual, last name, first name. MI): (including address if different from NO.1 Oa.) (last name. first name, MI): (attach Continuation Sheets SF-LLL-A, if necessarv) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): a. retainer $ actual olanned b. one-time free 12. Form of Payment (check all that apply): c. commission a.cash d. contingent fee b. in-kind: specify: e. deferred nature: f, other specify: value: 14. Enter 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 on item 11: 15. Continuation sheet(s) SF-LLL-A attached: DYes DNa 16. Information requested through this form authorized by Title 31 U.S.C. Section 1352 This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier Signature: above when this transaction was made or entered into. This disclosure is required pursuant to 31 Print Name: U.S.C 1352. This information will be reported to the Congress semiannually and will be available for Title: public inspection. Any person who fails to file the required disclosure snail be subject to a civil penalty Telephone No. of not less than $ 10,000 and not more than $ 100.000 for each such failure Date: