Laserfiche WebLink
<br />'-' ....., <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMS <br />0346-0046 <br /> <br /> (See reverse for oublic burden disclosure,) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a, contract D a. bidlofferlapplication o a. initial filing <br />b, grant b. initial award b. material change <br />c. cooperative agreement c. post-award For Material Change Only: <br />d.loan year quarter____ <br />e, loan guarantee date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 Is a Subawardee, Enter Name <br />DPrime o Subawardae and Address of Prime: <br />Tier ____, If known: <br />Conaresslonal District, If known: Conaresslonal District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Descriptlon: <br /> CFDA Number, if applicable: ______ <br />8. Federal Action Number, ifknown: 9. Award Amount, if known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, M/): different from No, 10a) <br /> (last name, first name, M/): <br /> (attach Continuation Sheet(sl SF-LLLA. ifnecesSB"') <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ------ o aclual o plannad o a. retainer <br /> o b. ona-lIma hie <br />12. Form of Payment (check all that apply): o c. commission <br />o e. cash D d. contingent fee <br />o b. in-kind: specify: nature _____ o e. deferred <br /> value o f. other, specify: <br />14. Brief Description of Services Performed or to be Performed and Dala(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated In Item 11: <br /> (attach Continuation Shee/(s) SF-LLLA. If nocossa",) <br />15. Continuation Sheetlsl SF-LLLA attached: Dyes DNo <br />16 Information requested through Ihill form Is authorized by tills 31 U.S.C. section r" I ( " ~~ ~ . <br />Signature: <br />. 1352. this lSlsdosure of lobbying a&tlvilies ia a material repreeentation 01 faa Print Name: AM ::rhWM.L~Lt /-lAM (' <br />upon which reliance waB plBcecI by the tier above when thl8 trensaction was made <br />or entered inta. Thlt (\lsdOsure Is required pursuant 10 31 U.S.C. 1352. This <br />Inlormatla'l wilt be reported 10 the ConlJ'llB seml-annualy and wiD be aV8illlble for Title: Pr~Jewf' <br />pubHc lnspectkn. Ally pers:N'\ who falll to fila Ihe requlr&d dllCloaul8 Ilhall be <br />subject to a civil penally of not lass lhat $10,000 and not mOI'8 than $100.000 fOJ Telephone No.: ('11~) 5<-t,.s'l-leS Date: ~_27-oZ, <br />each such failure. <br />. 7,. u. ..... . .. ... .. _I Authorized for Local Reproduction <br />FederaI\jseOllly: .. .... ....... . .. , .. Standard Form LLL (Rev, 7-97) <br />