DAYLE MCINTOSH CENTER 4 -2002 - Laserfiche WebLink

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....... '-' DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMS 0345-0046 See reverse for oublic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract D a. bidlofferlapplication 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 DPrlme o Subawardee and Address of Prime: Tier ____, if known: Conaresslonal District, If known: Canaressional District, If known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, Ifapplicab/e: 8. Federal Action Number, Ifknown: 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. 1 Oa) (last name, first name, MI): (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 D b. ana-lime fae 12. Form of Payment (check all that apply): o c. commission D a. cash D d. conllngant fee D b. in-kind: specify: nature _____ D e. defarred value D f. olhe,: apoclfy: 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: laUaell Continuation Shaa/ls) SF-LLLA, If necessarY) 15. Continuation Sheet(s) SF.LLLA attached: DYea [lNo 16 Information requesL8d through this form i8 lIulhorlzed by lilIe 31 U.S.C. seclion Signature: . 1352. This disclosure of lobbying acUvlUes 18 a material representation of 'act upon which reliance was placed by the liar above when this transaction wall made Print Name: Of entered into. This disclosure 18 raqulred pursuant to 31 U.s.C. 1352. Thil InJormaUa'l will be reported to the Congress semi-annualy entS wUl be available fer Title: pubic Inlpllctla'l. Any person who fail& to file the requi'ed dltc:lcsul8 shall be lubject lc a civil penalty cf net hlll1hat $10,000 and not more than $100.000 fer Telephone No.: Date: eac:h ludl failure. . . .... . ... ::\ Authorized for Local Reproduction Fede",1 H~l!Ollly:. .. . .. Slandard Fo"" LLL (Rev. 7-97)