MERCY HOUSE LIVING CENTERS (ESG 2002)

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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 0348.0046 (See reverse for pubiic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract D a. 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 DPrime D Sub awardee and Address of Prime: Tier __, if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicab/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/): different from No. 1 Oa) (last name, first name, M/l: (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 planned o a. retainer D b. one-Ume fee 12. Form of Payment (check all that apply): o c. commission D a. cash o d. contingent fee D b. in~kind; specify: nature I. D e. deferred value ------ Of. 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 Sheel(s) SF.LLLA, if necessary) 15. Continuation Sheet(s) SF.LLLA attached: DYes DNo 16 Information requested through this form is authorized by tilla 31 U.S.C. section Signature: . 1352. This disdosure of lobbying activilies Is 8 material IlIprellll!lntalion of fad: upon which reliance was placed by 1119 tier above when this transaction was made Print Name: or enlerEld into. This disdosure is required pursuant to 31 U.S.C. 1352. This informa1ia'l will be reported to the Congess seml-annualy ancl will be available for Title: pubic InspectiCJl. Any person who fails to file the requhtd dlsdosul9 shall be subject to a dvil penalty of not less thet $10.000 and not more than $100,000 for Telephone No.: Date: eactl such failure. Federal Use Only: -- ....... ...... .1 Authorized for local Reproduction ..... ..... -....< < Standard Form LLL (Rev. 7-97)