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Local Assistance Procedures Manual EXHBIT 10-R Disclosure of Lobbying Activities Exhibit 10-Q Disclosure of Lobbying Activities N/A DISCLOSURE OF LOBBYING ACTIVITIES COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ❑ a. contract ❑ a. bid/offer/application ❑ a. initial b. grant b. initial award b. material change c. cooperative agreement c. post -award d. loan For Material Change Only: e. loan guarantee year quarter_ f. loan insurance date of last report 4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and Address of Prime: ❑ Prime ❑ Subawardee Tier , if known Congressional District, if known Congressional District, if known 6. Federal Department/Agency: 7. Federal Program Name/Description: 8. Federal Action Number, if known: 10. a. Name and Address of Lobby Entity (If individual, last name, fust name, MI) 11. 12. 14. CFDA Number, if applicable 9. Award Amount, if known: b. Individuals Performing Services (including address if different from No. I Oa) (last name, first name, MI) (attach Continuation Sheet(s) if necessary) Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) $ ❑ actual ❑ planned a. retainer b. one-time fee Form of Payment (check all that apply): c. commission ❑a. cash d. contingent fee b. in-kind; specify: nature a deferred Value f. other, specify 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: (attach Continuation Sheet(s) if necessary) 15. Continuation Sheet(s) attached: Yes ❑ No ❑ ,� . 16. Information requested through this form is authorized by Title 31 U.S.C. Section 1352. This disclosure of lobbying reliance Signature: was placed by the tier above when his transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. Print Name: Pat Somerville, PE 1352. This information will be reported to Congress semiannually and will be available for public inspection. Any Vice President person who fails to file the required disclosure shall be subject Title: to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Telephone No.: 714.567.2755 Date: 4/6/2010 Authorized for Local Reproduction Federal Use Only: Rev 04-IM6 Standard Form - LLL Page 10-77 LPP 06-02 May 1, 2006