FATHERHOOD 101 1-2002 - Laserfiche WebLink

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. "~.'.,' ""'..'., ":.::'..::.:..,'...".....".,. '-' ...., Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden statement) Approved by OMB 0348-0046 1. Type of Federal Action O a. contract b. grant c. cooper ive agreement d. loan e. loan guar tee f. loan insura 4. Name and AdClresstof Rep ing Entity DPrime 0 Su Tier 2. Status of Federal Action O a. bid/offer/application b. Initial award c. post-award , if known: 3. Report Type O a. initial filing b. material change For Material Change Only year (yyyy) ____ quarter ____ date of last report (mm/dd/yyyy)_____ 5. If Report1ng Entity In No.4 Is SUbawardee, enter Name and Address of Prime Congressional District, if known Congressional District, if known 6. Federal Department/Agency Federal Program Name/Description 8. Federal Action Number, if known 10a. Name and Address of Lobbying Registrant (if individual, last name, first name, MI) dividuals Performing Services (including address ifdifferentfrom No. 10a.) (I t name, first name, MI) (attach continuation sheet(s) ifnecessa 11. Amount of Payment (check all that apply) 13. Type of Pay $ actual planned 0 a. 12. Form of Payment (check all that apply) 0 b. DL~ D~ o b. in~kind; specify: nature 0 d. value D e. deferred o f. other (specify) 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), e ployee(s), or Member(s) contacted, for Payment Indicated in Item 11 (attach continuation sheet(s) If necessaty) 15. Continuation sheets attached DYes D No 16. Information requested through this form is authorized by Sec.319, Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- 65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semiannually and will be available for pubiic inspection. Any person who fails to file the required disciosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Date (mm/dd/yyyy) &~If "<: Ir<?c~ r ~YI.Sprer (7/q) 911-77-2-8 1'2- /8- en... Print Name Title Telephone No. Federal Use Only: Authorized for Local Reproduction Standard Form-LLL (7/97)