Fillable Printable Disclosure Of Lobbying Activities
Fillable Printable Disclosure Of Lobbying Activities
Disclosure Of Lobbying Activities
10. a. Name and Address of Lobbying Registrant:
9. Award Amount, if known:
$
* Street 1
* City
State
Zip
Street 2
* Last Name
Prefix
* First Name
Middle Name
Suffix
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352
Approved by OMB
4040-0013
1. * Type of Federal Action:
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance
2. * Status of Federal Action:
a. bid/offer/application
b. initial award
c. post-award
3. * Report Type:
a. initial filing
b. material change
For Material Change Only:
year
quarter
date of last report
4. Name and Address of Reporting Entity:
Prime
SubAwardee
Tier if known:
* Name
* Street 1
Street 2
* City
State
Zip
Congressional District, if known:
6. * Federal Department/Agency:
7. * Federal Program Name/Description:
CFDA Number, if applicable:
8. Federal Action Number, if known:
b. Individual Performing Services(including address if different from No. 10a)
Prefix
* First Name
Middle Name
* Street 1
* City
State
Zip
Street 2
11.
* Last Name
Suffix
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 the 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 for 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 $100,000 for each such failure.
* Signature:
*Name:
Prefix
* First Name
Middle Name
* Last Name
Suffix
Title:
Telephone No.:
Date:
Federal Use Only:
Authorized for Local Reproduction
Standard Form - LLL (Rev. 7-97)
