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Local Assistance Procedures Manual <br />EXHBIT 10 -R <br />Disclosure of Lobbying Activities <br />Exhibit 10 -Q Disclosure of Lobbying Activities <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352 <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />❑ a. contract ❑ a. bid /offer /a pp lication ❑ a. initial <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post -award <br />d. loan For Material Change Only: <br />e. loan guarantee year quarter <br />f. loan insurance date of last report <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, <br />Enter Name and Address of Prime: <br />FiPrime FISubawardee <br />Tier , if known <br />Congressional District, if known <br />6. Federal Department /Agency: <br />8. Federal Action Number, if known: <br />10. a. Name and Address of Lobby Entity <br />(If individual, last name, first name, MI) <br />11. <br />12. <br />14. <br />Congressional District, if known <br />7. Federal Program Name /Description: <br />CFDA Number, if applicable <br />9. Award Amount, if known: <br />b. Individuals Performing Services (including <br />address if different from No. l0a) <br />(last name, first name, MI) <br />(attach Continuation Sheet(s) if necessary) <br />Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) <br />$ ❑ actual ❑ planned ❑ a. retainer <br />b. one -time fee <br />Form of Payment (check all that apply): c. commission <br />a. cash d. contingent fee <br />b. in -kind; specify: nature e deferred <br />Value f. other, specify <br />Brief Description of Services Performed or to be performed and Date(s) of Service, including <br />officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) if necessary) <br />15. Continuation Sheet(s) attached: Yes ❑ No ❑ <br />16. Information requested through this form is authorized by Title <br />31 U.S.C. Section 1352. This disclosure of lobbying reliance Signature: <br />was placed by the tier above when his transaction was made or <br />entered into. This disclosure is required pursuant to 31 U.S.C. print Name: <br />1352. This information will be reported to Congress <br />semiannually and will be available for public inspection. Any <br />person who fails to file the required disclosure shall be subject Title: <br />to a civil penalty of not less than $10,000 and not more than <br />$100,000 for each such failure. Telephone No.: Date: <br />Authorized for Local Reproduction <br />Federal Use Only: <br />Standard Form LLL Rev. 04 -28 -06 <br />Standard Form - LLL <br />Page 10 -77 <br />LPP 06 -02 May 1, 2006 <br />