Laserfiche WebLink
<br />\lIl '-' <br />Disclosure of Lobbying Activities <br /> <br />Approved by OMB 0348-0046 <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br /> <br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type <br /> D 8. contract o a. bid/offer/application o a. initial filing <br /> b. grant b. initiai award b. malerial change <br /> c. cooperative agreement c. post-award For Material Change Only <br /> d. loan year (yyyy) ____ quarter _____ <br /> e. loan guarantee <br /> f. loan insurance date of last report (mm/dd/yyyy)_________ <br />4. Name and Address'-of Reporting EntIty 5. If Reporting Entity In No.4 is Subawardee, enter Name and Address <br /> Dprime D Subawardee Tier ___ , if known: of Prime <br /> Congressional District, if known Congressional District, if known <br />6. Federal Department/Agency 7. Federal Program Name/Description <br /> - <br /> CFDA Number. if applicable ______ <br />8. Federal Action Number, if known 9. Award Amount. if known <br /> $ <br />10a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from No.1 Oa.) <br /> (if individual, last name, first name, MI) (last name, first name. Ml) <br /> <br />(attach continuation sheel(s) if necessary) <br /> <br />11. Amount of Payment (check all that apply) <br /> <br />13. Type of Payment (check all that apply) <br />D a. retainer <br />o b. one-time fee <br />D c. commission <br />D d. contingent fee <br />o e. deferred <br />D f. other (specify)__~_______________________ <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, <br />for Payment Indicated in Item 11 <br /> <br />value <br /> <br />$ <br /> <br />actual <br /> <br />planned <br /> <br />12. Form of Payment (check all that apply) <br />D a. cash <br />D b. in-kind; specify: nature <br /> <br />(attach continuation sheet{s) if necessary) <br />15. Continuation sheets attached DYes D No <br /> <br />16. Information requested through this form is authorized by Sec.319, <br />Pub. L.101-121, 103 Stat. 750, as amended by sec. 10; Pub. L.104- <br />65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />is a material representation of fact upon which reliance was placed <br />by the above when this transaction was made or entered into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. This information <br />will be reported 10 the Congress semiannually and will be available <br />for pubiic inspection. Any person who fails to file the required <br />disclosure shall be subjecllo a civil penalty of nolless Ihan $10,000 <br />and not more than $100,000 for each such failure. <br /> <br />Signature <br /> <br />Print Name <br /> <br />Title <br /> <br />Telephone No. <br /> <br />Date (mm/ddfyyyy) <br /> <br />Federal Use Only: <br /> <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />