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<br /> <br /> Local Assistance Procedures Manual EXHBIT 10-R <br /> Disclosure of Lobbying Activities <br /> <br /> Exhibit 10-Q Disclosure of Lobbying Activities <br /> DISCLOSURE OF LOBBYING ACTIVITIES <br /> COMPLETE TKIS 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 /> <br /> ? a. contract ? a. bid/offer/a lication ? a. initial <br /> pp <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 /> Prime ?Subawardee <br /> Tier , if known <br /> Congressional District, if known Congressional District, if known <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable <br /> 8. Federal Action Number, if known: 9. Award Amount, if known: <br /> 10. a. Name and Address of Lobby Entity b. Individuals Performing Services (including <br /> (If individual, last name, first name, MI) address if different from No. l0a) <br /> (last name, first name, MI) <br /> (attach Continuation Sheet(s) if necessary) <br /> 11. 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 /> 12. Form of Payment (check all that apply): c. commission <br /> a. cash d. contingent fee <br /> b. in-bind; specify: nature e deferred <br /> Value f. other, specify <br /> 14. 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: Standard Form - LLL <br /> Standard Form LLL Rev. 04-28-06 <br /> <br /> Page 10-77 <br /> LPP 06-02 ~ May 1, 2006 <br />