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Pap, un. Fie <br />2 1 LEMON <br />LCM WCH <br />Local Assistance Procedures Manual EXHIBIT 12-E <br />PS&E Checklist Instructions Attachment G <br />ATTACHMENT G DISCLOSURE OF LOBBYING ACTIVITIES <br />COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTWITTFR PURRTTANT Tn 11 TT c n , o <br />1. Type of Federal Action: <br />Fla. contract <br />b. grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />2. Status of Federal Action: <br />® a. bid/offer/application <br />b. initial award <br />c. post -award <br />3. Report Type: <br />® a. initial <br />b. material change <br />For Material Change Only: <br />year_ quarter_ <br />date of last report _ <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, <br />Enter Name and Address of Prime: <br />Prime n Subawardee <br />EXCEL PAVWG COMPAW Tier , if known <br />GA 9'08 <br />Congressional District, if known <br />6. Federal Department/Agency: <br />8. Federal Action Number, if known: <br />10. a. Name and Address of Lobby Entity <br />(If individual, last name, first name, MI) <br />Congressional District, if known <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable <br />9. Award Amount, if known: <br />b. Individuals Performing Services (including <br />address if different from No. 10a) <br />(last name, first time, MI) <br />(attach Continuation Sheet(s) if necessary) <br />11. Amount of Payment (check all that apply) <br />$ [] actual planned <br />12. Form of Payment (check all that apply): <br />a. cash — <br />b. in-kind; specify: nature <br />13. Type of Payment (check all that apply) <br />a. retainer <br />b. one-time fee <br />c. commission <br />d. contingent fee <br />e deferred <br />f, other, specify <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including <br />officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) if ne ssary) <br />15. Continuation Sheet(s) attached: Yes 11 No <br />16. Information requested through this form is authorized by Title <br />31 U.S.C. Section 1352. This disclosure of lobbying reliance <br />was placed by the Ger above when his transaction was made or <br />entered into. This disclosure is required pursuant to 31 U.S.C. <br />1352. This information will be reported to Congress <br />semiannually and will be available for public inspection. Any <br />person who fails to file the required disclosure shall be subject <br />to a civil penalty of not less than $10,000 and not more than <br />$100,000 for each such failure. <br />Federal Use Only: <br />OB 12-04 <br />Signature: Q1,11 <br />Print Name: L40^i1fd14 PREA ENT <br />Telephone No.: (562) 599-5841 Date: SF�, 9 2 <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Page 1.2-35 <br />June 29, 2012 <br />