WISE PLACE 5 -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 Approved by OMS 0348-0046 See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract D a. bidlofferlapplication 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 o Prime o Sub awardee and Address of Prime: Tier ____. if known: Connresslonal District, if known: Conaressional District. if known: 6. Federal Department/Agency: 7. Federal Program NamelDescription: CFDA Number. ifapplicable: 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, MI): different from No. lOa) (last name. first name, MI): (attach Continuation Sha.t(s) SF-LLLA. if nece..arv) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ------ o actual o planned o a. retainer o b. one-time leo 12. Form of Payment (check all that apply): o c. commission o a. cash o d. contlngont leo o b. in-kind; spoclfy; nature ----- o e. deferred value --- o f. othor, .poclfy; 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including offlcer(s), employee(s), or Member(s) contacted, for Payment Indicated In Item 11: (attach ConUnuatlon Sheet(s) SF-LLLA. If necessary) 15. Continuation Sheetlsl SF.LLLA attached: DYe. DNo 16 Inrormation requested Ihrough Ihls form is 8ulhorlzed by litIe 31 U.$.C. nellon Signature: . 1352. This diadDSUf8 of lobbying Bellville. is a material ttpr..ntallon of tact upon whidl reliance was placed by the tier above when this transacUon waa made Print Name: or ententd into. ",11 dladosufe is required puI1Iuanl to 31 U.S.C. 1352. this informalloo will be reportedto \he Corven sem~.nnualy andwKI be avalllblefor Title: pubic Inspecllcn. AAy person who fallB 10 file the required dlsdoBUnl thaD be Bubject 10 a dvil penalty of notlen thai $10,000 and not mare than $100.000 for Telephone No.: Date: each sudl failure. ....... . . ... .. ... ...... -C- 1- Authorized for local Reproduction Federal Use Only: . .. .. .... .. .. Standard Form LLL (Rev. 7-97) I