HomeMy WebLinkAboutexhibit 5-lobbyingApproved by OMR
0341.0046
ATTACHMENT B
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse fa public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3.. Report Type:
El
ID
�oKa/appiicatioa
a Cnn
b. tb.
c. operative agreement
d. loan
e. loan guarantee
f. loan insurance
a.brdltraCt
b. initial award
c. post -award
L btitial filing
metals! eho
For Material Clump Only;
year quarter
date of last report
4. Name and Address of Reporting Entity
:..;....,
❑ Prime ❑ Subawardee
Tier
, ... ,; , , : • - ..
. (fknown:
5. If Reporting Eadty in No 4 is Subawardee, Enter Name
w , fitd'Addrifs of Prime:.` ... ,.., .......... _ _ . .. ... , ....
Congressional District, if known:
Congressional District, (f known:
6. Federi1 Department/Agency: .
7. Federal Program Name/Description:
•
CFDA Number: jf applirabk:
3. Federal Action Number, If known:
9. Award Amount, {(known:
$
10. a. Name iced Address of L.abbyine Entity
(al i,tdividuol, last name, first name, MI):
(attach Continuation Sheets)
b. Individuals Performing Services (includins address {f
d(0erent from No.1Oa)
(last name, first name, MI):
SF•Wii. if necessary)
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Signature:
D.a.t Name:
Title;
. Telephone No.: Date:
Prue who
to a clrq penalty or Dot
web hart
Uu Only:
Authorised for Local Reproduction
Standard Elam - Lie. {Rev 7 - 97)
Form DEP 55-221 (01101)
•
DEP Agreement No. LW4b2, Attachment B, Page 1 or 2
"INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at
the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31
U.S.C. section 1352. The filing of a form is required for each payment or agreement to snake payment to any
lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered
Federal action. Complete all Items that apply for both the initial filing and material change report- Refer to the
Implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to
influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material
change to the information previously reported, enter the year and quarter in which the change occurred.
Enter the date of the` least p"teeloittly 'subliitittecl report b f the'reporting entity forthis covered Federal
action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional
District, if known. Check the appropriate classification of the reporting entity that designates if it is or
expects to be, a prime or. subaward recipient. Identify the tier of the subawardee, e.g., the first
subawardee of the prime is the 1st tier. Subawards include but are not Iimited to subcontracts,
subgrants and contract awards under grants.
5. If the organization fling the report in item 4. checks "Subawardee", then enter the full name, address,
city, state and zip code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award orloan commitment. Include at least one
organizational level below agency name, if known. For example, Department of Transportation, United
States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter
the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements,
loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in
item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB) number; grant announcement
number; the contract, grant, or loan award number; the application/proposal control number assigned
by the Federal agency). Include prefixes, e.g., "RFP-DE-90.001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,
enter the Federal amount of the award/loan commitment for the prime entity identified In item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting
entity identified in item 4 to Influence the covered Federal action.
(b) Enter the full names of the Individual(s) performing services, and include full addresc if different
from 10 (a). Enter Last Name, First Name, and Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title and telephone number.
According to the Paperwork Reduction Act. as amended, no persons are required to respond to a collection of Information unless It
displays a valid OMB Control Number. The valid OMB control number for this information collection is OMB No. 0340•0046. Public
reporting burden for this collection of information is estimated to average 30 minutes per response, Including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden. to the OMce of !Management and Budget. Paperwork Reduction Project (034840046). Washington, D.C. 20503.
Form DEP 55-221 (O10W )
DEP Agreement No. LW462, Attachment B,1'agv 2 of 2