ANAHEIM INTERFAITH SHELTER 2-2002

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'-" . 'WI DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMB 0348-0046 (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract Da. bid/offer/application D a. initial filing b. grant b. initial 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 o Prime o Subawardee and Address of Prime: Tier ____, ifknown: Con~ressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicab/e: _________ 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, M/): differentfrom No. 10a) (last name, first name, M/): (attach Continuation Sheet(s) SF-LLLA. if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ------ D actual D plannad o a. retainer o b. one-time fee 12. Form of Payment (check all that apply): D c. commission o a. cash D d. contingent fee D b. in-kind; specify: nature -------- o e. deferred value ---~--- D 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 Sheetls) SF-LLLA attached: DYes ONe 16 Information requested through this form is authorized by tiUe 31 U.S.C. section Signature: . 1352. This disclosure of lobbying activities is a malerial representation of fact upon which reliance was placed by the tier above when this transaction was made Print Name: or entered into. This disclosure is required pUlSUsnt to 31 U.S.C. 1352. This informauq! wUI be reported to lI1e Congess semhannualy and will be available for Titie: pub~c inspectiq!. Any person who fails to file 1118 requied disdOSUIe shall be subjecllo a civil pena!ty of not less lI1at S10,OOO and not more than S100,oOOfot Telephone No.: Ddte: each sudl failure. Federal Use Only: ..1 Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)