Laserfiche WebLink
<br />'-' <br /> <br />-..",I <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMB <br />0348-0046 <br /> <br /> 'See reverse for public burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a. contract D a. bid/offer/application D a. initial filing <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-award For Material Change Only: <br />d.loan year quarter ___ <br />e. loan guarantee date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br />o Prime o Subawardee and Address of Prime: <br />Tier ____, if known: <br />Congressional District, if known: Congressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, iast name, first name, M/): different from No. 10a) <br /> (last name, first name, MI): <br /> (anach Continuation Sheatla) SF-LLLA. Ir neoessa/y) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ----- o actual o planned o a. retainer <br /> o b. one-tIme fee <br />12. Form of Payment (check all that apply): o c. commission <br />o a. cash o d. contingent fee <br />o b. in-kind; specify: nature ------ o a. deferred <br /> value --- o f. other; spaclfy: <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated In Item 11: <br /> (anach Continuation Shast(s) SF-LLLA. If naoassBIY) <br />15. Continuation Sheet(s) SF-LLLA attached: OYe. ONo <br />16 Information requested through this form Is authorized by till. 31 u.s.c. ..cllon Signature: <br />. 1352. This disclosure of lobbying actlvltiu is a materiel reprtl8l'll8tlon of fad <br />upon which reliance was pl.cad by the tier abovewhen this trensaction was mach, Print Name: <br />or entered Into. This dlsdosure is required punuam to 31 U,S.C. 1352. This <br />infonNlUal wilt be reported to the Congess seml-annuely end wW be available for Title: <br />pubic inspedla"l. Ally person who falls 10 file lhe requi'ed dlldoaure shall be <br />subject to 8 eM! penalty of not lesl that $10,000 and not more than $100,000 for Telephone No.: Date: <br />each auchfellure. <br />.. ..... .. ........ .. ..-::1 Authorized for Local Reproduction <br />Federall,Jsl! Only: . . . . . .. . ... .. Standard Fonn LLL (Rav. 7-97) <br />