Laserfiche WebLink
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 034e-0046 <br />(See reverse for public burden disclosure.) <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />®a. contract <br />Nq}a. bid/offer/application <br />F a. initial filing <br />b. grant <br />b. initial award <br />b. material change <br />c. cooperative agreement <br />c. post -award <br />For Material Change Only: <br />d. loan <br />year __ quarter <br />e. loan guarantee <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />❑ Prime ❑ subawarde , <br />and Address of Prime: <br />Tier__, if known: <br />NA <br />NQ <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />'T <br />CFDA Number, if applicable: x� <br />8. Federal Action Number, if known: <br />9. Award Amount, if known: <br />NA <br />$ NA <br />10. a. Name and Address of Lobbying Entity <br />b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): <br />different from No. 10a) <br />( last name, first name, MI): <br />NA <br />NA <br />attach Continuation Sheets <br />SF-LLLA, if necessary) <br />11. AmountofPayment (check all that apply): <br />13. Type of Payment (check all that apply): <br />$ _ j x ❑ actual ❑ planned <br />❑ a. retainer <br />❑ b. one-time fee <br />❑ c. commission N <br />12. Form of Payment (check all that apply): <br />❑ a. cash <br />❑ d. contingent fee <br />❑ b. in -kind; specify: nature <br />❑ e. deferred <br />value <br />❑ I. other; specify: <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 />NA <br />(attach Continuation Sheet(s) SF-LLLA, i/ ece ry) <br />15. Continuation Sheets SF-LLLA attached: ❑ Yes <br />❑ No <br />16. Inrormation ` uesled through this Mm, is authodmd by due 31 U.S.C. sep <br />1352. Time dial we of bbbyhp ac hies Is a material representation of fecl <br />Signature: <br />g <br />-- <br />Print Name: G vl <br />upon which relisnm we plsced by the Wr above whm this transaction we made <br />or entered into. This disdosum is mused WrsuMA W 31 U.S.C. 1%2. This <br />Title: i) f2C.- r <br />IM tlon will be reported b Me Co `ass saM-wresaly and wa be available ter <br />public MspMftn- Arty person who teas M file Me required disdosw shall be <br />Telephone No.:—OL p ?�C (Z Date:g <br />subject to a d penalty a wt bss Mal flo.000 &W `rot more Man fioo,000 for <br />eaph each failure. <br />t0i _00fxdl), a Only: <br />Authorized for Local Reproduction <br />Standard Form LLL (Rev. 7-97) <br />