HomeMy WebLinkAboutlobbying activitiesDISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for public burden disclosure.)
Approved by OMB
0348-0046
1. Type of Federal Action:
2. Status of Federal
Action
award
3. Report Type:
1›, a. contract
b a. bid/offer/application
b. initial
c. post -award
j� a. Initial filing
b. material change
b. grant
c, cooperative agreement
d. loan
e. loan guarantee
f. loan Insurance
For Material Change Only:
Year Quarter
date of last report
4. Name and Address of Reporting Entity:
✓Prime ® Subawardee
Tier , if known:
5. If Reporting Entity in No. 4 is Subawardee, Enter Name and
Address of Prime:
Congressional District, if known:
Congressional District, if known: / 3� It , 2-0a 2-1
6. Federal D,eepartment/Agency:ee -- [[ {,�, �j�
iA. S. b fi- of 1"'L.F�, f1--, 6 iut i, -r v ice
OM Itn 5 ones 'Q, 2/v'C16 Act m;n .
7. Federal Program NamelDescription:
CFDA Number, if applicable: q 3 ,'2 5 c
8. Federal Action Number, if known:
9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Entity
(if individual, last name, first name, MO.
N/A'
b. Individuals Performing Services (including address if different
from No. f 0a.)
(last name, first name, MI):
ft
11. Information requested through this form is authorized by
title 31 U.S.C. section 1352. This disclosure of lobbying
activities is a material representation of fact upon which
'reliance was placed by the tier above when this transaction
was made or entered into. This disclosure Is required
pursuant to 31 U.S.C. 1352. This information will be reported
to the Congress semi-annually and will be available far
public inspection. Any person who fails to file the required
disclosure shall be subject to a civil penalty of not less than
$10,000 and not more than 3100,000 for each such failure.
Signature*
�f /
Print Name: /"f y f 0(ra ide
'Title* XA 4a
Telephone No ����3�� y�s3 pate: Cl
Authorized for Local "eproduction
Standard Form - LLL (Rev. 7-97)