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Local Assistance Procedures Manual Exhibit 12-H
<br />Sample Bid
<br />INSTRUCTIONS FOR COMPLETION OF SF-LLL,
<br />DISCLOSURE OF LOBBYING ACTIVITIES
<br />This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or
<br />receipt of covered Federal action or a material change to previous filing pursuant to title 31 U.S.C. section 1352. The filing of a
<br />form is required for such payment or agreement to make payment to lobbying entity for influencing or attempting to influence an
<br />officer or employee of any agency, a Member of Congress an officer or employee of Congress or an employee of a Member of
<br />Congress in connection with a covered Federal action. Attach a continuation sheet for additional information if the space on the
<br />form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing
<br />guidance published by the Office of Management and Budget for additional information.
<br />I. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence, the
<br />outcome of a covered Federal action.
<br />2. Identify the status of the covered Federal action.
<br />3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
<br />information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last,
<br />previously submitted report by this reporting entity for this covered Federal action.
<br />4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District if known.
<br />Check the appropriate classification of the reporting entity that designates if it is or expects to be a prime or subaward
<br />recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the first tier. Subawards include
<br />but are not limited to subcontracts, subgrants and contract awards under grants.
<br />5. If the organization filing the report in Item 4 checks "Subawardee" then enter the full name, address, city, state and zip
<br />code of the prime Federal recipient. Include Congressional District, if known.
<br />6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organization level
<br />below agency name, if known. For example, Department of Transportation, United States Coast Guard.
<br />7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of
<br />Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments.
<br />8. Enter the most appropriate Federal identifying number available for the Federal action identification in item 1 (e.g.,
<br />Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant, or
<br />loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g.,
<br />"RFP-DE-90-001."
<br />9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal
<br />amount of the award/loan commitments for the prime entity identified in item 4 or 5.
<br />10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified in
<br />item 4 to influenced the covered Federal action.
<br />(b) Enter the full names of the individual(s) performing services and include full address if different from 10 (a). Enter
<br />Last Name, First Name and Middle Initial (MI).
<br />It. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (item 4) to the lobbying
<br />entity (item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that
<br />apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
<br />12. Check the appropriate box. Check all boxes that apply. If payment is made through an in -kind contribution, specify the
<br />nature and value of the in -kind payment.
<br />13. Check the appropriate box. Check all boxes that apply. If other, specify nature.
<br />14. Provide a specific and detailed description of the services that the lobbyist has performed or wil I be expected to perform
<br />and the date(s) of any services rendered. Include all preparatory and related activity not just time spent in actual contact
<br />with Federal officials. Identify the Federal officer(s) or employee(s) contacted or the officer(s) employee(s) or Member(s)
<br />of Congress that were contacted.
<br />15, Check whether or not a continuation sheet(s) is attached.
<br />16, The certifying official shall sign and date the form, print his/her name title and telephone number.
<br />Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for
<br />reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
<br />collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
<br />including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project
<br />(0348-0046), Washington, D.C. 20503. SF-LLL-Inewdions Rev.06-04.90ttENDIFX
<br />LPP 18-01
<br />Page 13 of 22
<br />Januarv2019
<br />20E-43
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