WOMEN'S TRANSITIONAL LIVING 8 -2002

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'-' ~ DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 V.S.C. 1352 Approved by OMS 0348-0046 See reverse for oublic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: o a. contract Oa. bid/offer/application o 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 Subawardee and Address of Prime: Tier ____, if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicab/e: ______ 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): differentfrom No. 10a) (last name, first name, MI): (attach COntinuation Shset(s) SF-LLLA, ifnecessarv) 11. Amount of Payment (check ali that apply): 13. Type of Payment (check ali that apply): $ ------ o aclual o plannad o a. ratalnar D b. one-time fee 12. Form of Payment (check ali that apply): D c. commission o a. cash o d. contlngant fee o b. in.kind; spaclfy: nature -------- o e. defarred value --- o f. othar; specify: 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: (aUach ConYnuatlon Sheetls) SF.LLLA, If necesserv) 15. Continuation Sheet/s) SF.LLLA attached: o v"" ONo 16 Information requested th/tlugh this form is authorized by UUt 31 U.S.C. section Signature: '1352. This disdosure of lobbying activities is a material r&pr&Elenlalion offaet upon which relial\CEl was placed by the tier 8DovllIwhen this transaction was made Print Name: DI'" entered into. Thlt dlsdosure Is required pursuant to 31 U.s.c. 1352. This Inform8~a1 will be reported to \he Congress seml-annualy and wIU be avall&b1e for Title: pubic Il\Spectloo. Any person who falls to "Ie the required dllSClosurt shall be subject to a civil penalty of not less that $10,000 and not mQ1"8 than S100.ooo for Telephone No.: Date: aachsuchfallura. . ., ,.. .'... ' ." .'... .. ,. -1 Authorized for Local Reproduction Federall)se Only: . > . Standard Form LLL (Rev. 7-97)