ACHIEVEMENT INSTITUTE - 2003 - Laserfiche WebLink

Home Browse Search

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 See reverse for public burden disclosure. 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ~ a. contract ! a. bid/offer/application ~ a. initial filing b. grant ~ b. n t a award~ b. material change c. cooperative agreement c. post-award For Material Change Only: d. loan year ....... quarter ......... e. loan guarantee date of last report ............ f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name [] Prime [] Subawardee and Address of Prime: Tier ....... if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: (3FDA Number, if applicable: ............. 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. l Oa ) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLLA, i£necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ........... [] actual [] planned [] a. retainer [] b. one-time fee 12. Form of Payment (check all that apply): [] c. commission [] a. cash [] d. contingent fee [] b. in-kind; specify: nature ....... [] e. deferred value .......... [] f. other; specify: ......................... 14. Brief 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 in Item 11: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: [] Yes [] No 1 6, ~nforma~on requested through this f~m is authorized by lltle 31 U SC secUon Signature: or entered into This dlsdosure is required pursuant to 31 USC. 1352. Th~s Print Name: public inspection. Any person who fai~s to ~e the required disclosu~ sh~{l be Title: each such fail~re Telephone No.: .................... Date: Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev 7-97)