WISE PLACE 7 -2002 - Laserfiche WebLink

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'-" -.....I 1. Type of Federal Action: o a. contract b. grant c. cooperative agreement d.loan e. loan guarantee 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: Oa. bid/offer/application 0 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, ifknown: 9. Award Amount, ifknown: $ b. Individuals Performing Services (including address if different from No. 10a) (last name, first name. MI): 10. a. Name and Address of Lobbying Entity (ifindividual, last name, first name, M/): aUsch ConUnustion Shaat(s) SF-LLLA, ir necesssry) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ 0 ectual 0 planned 0 a. retainer D b. one-time fee o c. commission o d. contingent lee o e. deferred o l. other; specify: 12. Form of Payment (check all that apply): o a. cash o b. in..kindj 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: laUsch ConUnuation She./!s) SF-LLLA. if necessary) 15. Continuation Sheet s SF.LLLA attached: 0 Ve. 0 No 16 Information requested through this form Is authorized by Uti. 31 u.s.c. section Signature . 1352. This disoosure of k1bt:rt1ng activilills 18 8 material repre68fltetion of fad . : uponwhlchrellancewuplsc:edbythalierabovewhan lhls transactlon WlI made P' t N Of entered Into. This disdosure 1& required pul5Uant to 31 U.s.c. 1352. This nn sma: InformaUQ'l will be reported to lhe ConIir8SS aemi.annualy and will be aVllilllblll for pubic inspectla1. My person who falls to nle the required d1sdosul'll thall be Title: subject to a civil penatty of not less that $10,000 ar..:1 notmat8 than $100,000 for ..... ,"do ~.".. Telephone No.: Federal Use Only: ,.-,','- ...'..-"...-..,....-'.-.:-... Date: Authorized for Local Reproduction Standard Form LLL (Rav. 7-97)