MERCY HOUSE LIVING CENTERS (ESG 2002) (2)

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1. Type of Federal Action: D a. contract b. grant c. cooperative agreement d.loan e. loan !)uarantee f. loan insurance 4. Name and Address of Reporting Entity: o Prime 0 Subawardee Tier ____. if known: '-' DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 See reverse for ublic burden disclosure. 2. Status of Federal Action: 3. Report Type: Da. bid/offer/application D a. initial filing b. initial award b. material change c. post-award For Material Change Only: year ____ quarter ____ date of last report _________ " ..... '-' Approved by OMS 0348-0046 5. If Reporting Entity in No.4 is a Subawardee, Enter Name and Address of Prime: Con ressional District, if known: 6. Federal Department/Agency: Con ressional District, if known: 7. Federal Program Name/Description: CFDA Number. if applicab/e: ______ 8. Federal Action Number, if known: 9. Award Amount, if known: $ b. Individuals Performing Services (including address if different from No. 10a) (tast name, first name. MI): 10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI): (attach Continuat;on Sheet(s) SF..LLLA, ifnecessa 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ o actual o planned o e. retainer o b. one-time fee o c. commission o d. contingent lee o e. deferred o I. other; specify: 12. Form of Payment (check all that apply): o a. cash o b. in.kind; specify: nature ______ value ______ 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 Sheet s SF.LLLA attached: 0 Yes 0 No 16 Information requesled through this form is authorized by title 31 U.S.C. section Signature: . 1352. This disclosure of lobbying activities Is a material representation of fact upon which reliance was placed by them above when this transaction was made P' t N or entered into. This disdosure is required pUmJant to 31 U.S.C. 1352. This nn ame: infolTTlBlicn will be reported to the Cong-ess semi-annualy and wilt be available for TI'tle'. pubic inspeetiQl. Any person who fails to file the requred disdosul8 shall be subject to a civil penalty of not less thst $10,000 and not more than $100,000 for each sudl faillre. Telephone No.: Federal Use Only: Date: Authorized for local Reproduction Standard Form LLl (Rev. 7-97)