Laserfiche WebLink
DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br />(See reverse for public burden disclosure.) <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />❑ a. contract <br />❑ a. bid/offer/application <br />❑ a. initial filing <br />b. grant <br />b. initial award <br />b. material change <br />c. cooperative agreement <br />c, post -award <br />For Material Change Only: <br />d.loan <br />year quarter <br />e. loan guarantee <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address <br />❑ Prime ❑ Subawardee <br />of Prime: <br />Tier if known: <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable: <br />8. Federal Action Number, if known: <br />9. Award Amount, if known: <br />$ /- j, 5'% <br />10. a. Name and Address of Lobbying fL' %j� <br />b, Individuals Performing Services ( including address )�`1 <br />Entity <br />if different from No. 10a) i <br />( if individual, last name, first name, MI): <br />(last name, first name, MI): <br />(attach Continuation <br />Sheet(s) SF-LLLA, if necessary) <br />11. Amount of Payment ( check all that apply): <br />13. Type of Payment ( check all that apply): <br />$ ❑ actual ❑ planned tvIA <br />❑ a. retainer <br />❑ b. one-time fee <br />❑ c. commission <br />❑ d. contingent fee <br />12. Form of Payment ( check all that apply):} <br />El a. cash <br />❑ e. deferred <br />❑ b. in -kind; specify: nature <br />❑ f. other; specify: <br />value <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: 7 <br />(attach Continuation Sheet(s) SF-LLLA, if necessary) <br />15. Continuation Sheet(s) SF-LLLA attached: ❑ Yes No <br />16. <br />Signature: <br />Information requested through this form is authorized by title 31 <br />Print Name: A`c i <br />U.S.C. section1352. This disclosure of lobbying activities is a <br />Title: 14i'. Y/!i <br />material representation of fact upon which reliance was placed <br />Telephone No.: Z <br />by the tier above when this transaction was made or entered <br />into. This disclosure is required pursuant to 31 U.S.C. 1352. This <br />information will be reported to the Congress semi-annually and <br />will be available for public inspection. Any person who fails to file <br />the required disclosure shall be subject to a civil penalty of not <br />less that $10,000 and not more than $100,000 for each such <br />failure. <br />Authorized for Local Reproduction <br />Federal Use Only: <br />Standard Form LLL Rev. 7-97) <br />EXHIBIT C <br />