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Local Assistance Procedures Manual <br />Exhibit 12-H <br />SamDle Bid <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />rIa. contract a. bid/offer/application a. initial <br />b. grant b. initial award b. material change <br />c, cooperative agreement c. post -award <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />4. Name and Address of Reporting Entity <br />Prime ❑ Subawardee <br />Tier , if known <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 />For Material Change C <br />year_ quarter <br />date of last report <br />5. If Reporting Entity in No. 4 is Subaw di <br />Enter Name and Address of Prime - <br />Congressional Congressional Distri if known <br />7. Federal Yroaram ame/Descrin <br />CFDA No <br />/?6er, if applicable <br />9. Award mount, if known: <br />Individuals Performing Services (including <br />address if different from No. 10a) <br />(last name, first name, MI) <br />(attach C tinuation Sheet(s) if necessary) <br />11. Amount of Payment (check all that ply) 13. Type of Payment (check all that apply) <br />$ actual planned a. retainer <br />b. one-time fee <br />12. Form of Payment (check al at apply): C. commission <br />Ba. cash d, contingent fee <br />b. in -kind; spe y: nature a deferred <br />value f other, specify <br />14. Brief Descriptio of Services Performed or to be performed and Date(s) of Service, including <br />officer(s), cm yee(s), or member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) if necessary) <br />/16.�- <br />oation Sheet(s) attached: Yes No <br />n requested through this form is authorized in �aspla. tion 1352. This disclosure of lobbying Signature: <br />as placed by the tier above when his transaction a ii <br />was made or entered into. This disclosure is required Print Name: Edward J. Carlson <br />pursuant to 31 U.S.C. 1352. This information will be <br />reported to Congress semiannually and will be available for Vice President <br />public inspection. Any person who fails to file the required Title: <br />disclosure shall be subjectto a civil penalty of not less than <br />$10,000 and not more than $100,000 for each such failure. Telephone No.: 951-736-7600 Date: I <br />Federal Use <br />LPP 18-01 <br />20E-42 <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Page 12 of 22 <br />January2019 <br />