HomeMy WebLinkAboutLobbying ActivitiesDISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
F7 a. contract
F7a. bid/offer/application
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
El Prime ❑ 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, if applicable:
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, Ml):
different from No. 10a)
( last name, first name, Ml):
(attach Continuation Sheet(s)
SF-LLLA, if necessary)
11. Amount of Payment (check all that apply):
13. Type of Payment (check all that apply):
$ ❑ actual ❑ planned
❑ a. retainer
b. one-time fee
❑ c. commission
12. Form of Payment (check all that apply):
❑ a. cash
E] d. contingent fee
b. in-kind; specify: nature
❑ e. deferred
value
f. other; 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:
Allo Lo br y,iv,e T-" V r s
(attach Continuation Sheet(s) SF-LLLA, if necessary)
15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No
Information requested through this form is authorized by fitle 31 U.S.C. section
16.1352.
Signature:
This disclosure of lobbying activities Is a material representation of fad
upon which reliance was placed by the tier above when this transaction was made
print Name: 7-' Z //i ��,✓
&"r
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
--a
information will be reported to the Congress semi-annualty and will be available for
public Inspection. Any person who fails to file the required disclosure shall be
Title: H r,-4rL
Telephone No.: ,� 6 �6 S'// Date:
subject to a civil penalty of not less that $10,000 and not more than $100,000 for
each such failure.
Federal Use Only:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)