3-3 - Appendix C - Required Forms CMAR Austin MS.pdf

Paulding County School District

Appendix C – Required Forms

The following pages contain forms that must accompany the submittal packet. If you have any questions or need clarification, contact purchasing@paulding.k12.ga.us.

P

Vendor Registration Form

Engage, Inspire, Prepare

Instructions:

1. The preferred method for completing this form is electronic; if you choose to complete the form by hand, please print legibly in blue ink and clearly distinguish numbers, for example, use Ø for zero and 7 for seven.

2. Print and sign the form.

3. See Application Submittal section at the end of this document; for options to submit to PCSD.

Name of School requesting new supplier/vendor: _________________________________________

Business Information Legal Business Name:

DBA (Doing Business As) Name:

Address:

City:

State: Zip:

Web Address:

Taxpayer Identification Number TIN (W-9 Form Also Required): Employer ID Number (EIN) or

Social Security Number (SSN) Is this For New Vendor Addition or Change of Existing Information? Add Change – Existing Vendor ID

Related Parties Disclosure: Are you a current employee of Paulding County School District (PCSD)? Yes No

Do you have immediate family members that are employed with PCSD? Yes No If yes; Name: Relation:

List additional immediate family members and relation here:

Contact Information General Contact Name:

Phone: Fax:

General Contact Email Address:

Purchase Order Contact Name:

Purchase Order Email Address (Note: For Electronic PO Delivery):

Payment/Remittance Information Business Name:

Remittance Address:

City:

State: Zip:

Accounts Receivable Contact Name:

Accounts Receivable Email Address:

Payment Terms

30 days: 60 days: Do you accept payment via P-Card?: Yes No

Vendor Registration Form

Vendor Business Type

Are you primarily a supplier of goods or services? Goods Services In a few short words, what is the primary good/service that you provide?

Paulding County Invoicing Requirements:

Unless otherwise noted, all invoices are to be sent to the Accounts Payable Department via USPS or Email.

USPS:

Accounts Payable Paulding County School District 3236 Atlanta Highway Dallas, GA 30132

Email:

accountspayable@paulding.k12.ga.us

Application Submittal:

USPS:

PCSD Procurement Department Paulding County School District 3236 Atlanta Highway Dallas, GA 30132

Or

Email:

purchasing@paulding.k12.ga.us

Required Forms:

The following forms are REQUIRED to be submitted with this application.

Failure to submit these forms will delay approval and entry into our supplier database.

1. A completed and signed IRS form W-9 (Rev. March 2024)

2. Applicable E-verify Affidavit per the Georgia Security & Immigration

Compliance Act as amended, O.C.G.A. 13-10-90 et.seq.

Disclaimer: Receipt of this application by the District neither implies or guarantees any contract or obligation to purchase goods or services from applicant.

*PCSD Does not accept payment terms shorter than Net 30.

Representative Signature Date Representative Printed Name

PCSD Central Office Use Only:

Vendor #: __________________

1099: Y ____ N____

Date Entered: _______________

Supplier/Vendor Application Request Forms (Please type or legibly print & compete all required sections)

Engage. Inspire. Prepare.

Determine how to comply with the GA Security & Immigration Act

This section is related to the GA Security & Immigration Compliance Act, O.C.G.A. §13-10-90 et seq. The chart below may assist you and your organization in determining whether these documents are applicable to you or the good/services your business provides. If in doubt as to whether a document should be completed and submitted, it is recommended that the vendor submit the information that best represents your organization in the flowchart below. If clarification is needed, contact the Purchasing Department via email at purchasing@paulding.k12.ga.us.

GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT, AS AMENDED BY THE ILLEGAL

IMMIGRATION REFORM ACT OF 2011, O.C.G.A. 13-10-90, ET AL.

If you are providing physical performance of services to the Paulding County School District (PCSD), the applicable Georgia Security and Immigration Compliance documents found here must be completed, signed, notarized, and submitted with your bid or proposal.

1. The PCSD shall comply with the Georgia Security and Immigration Compliance Act, as amended, Act

O.C.G.A. 13-10-90 et. seq.,

2. In order to insure compliance with the Immigration Reform and Control Act of 1986 (IRCA), D.L. 99-603, and the Georgia Security and Immigration Compliance Act, as amended by the Illegal Immigration Reform Act of 2011, O.C.G.A. 13-10-90 et. seq., (collectively the “Act”), the Vendor (“Contractor”) Must initial the statement applicable to Contractor below:

(a) (Initial here) Contractor warrants that, Contractor has registered at https://e-verify.uscis.gov/enroll/ to verify information of all new employees in order to comply with the Act; is authorized to use and uses the federal authorization program; will continue to use the authorization program throughout the contract period; Contractor further warrants and agrees Contractor shall execute and return any and all affidavits required by the Act and the rules and regulations issued by the Georgia Department of labor as set forth at Rule 300-10-1-.01 et. seq.; or

(b)_______ (Initial here) Contractor represents and warrants that it does not physically perform any service within the State of Georgia pursuant to O.C.G.A. 13-10-90 et. al. and thus does not have to comply with the foregoing Georgia law

(c) (Initial here) Contractor represents and warrants that it has no employees and does not intend to hire employees to perform contractual services and thus has provided a U.S. state-issued driver’s license or ID card in lieu of an affidavit, which license or ID card was issued by a State that verifies lawful immigration status before issuing the license of ID card. If my status changes I will, before hiring any employees, immediately notify the District in writing and provide all affidavits required (Complete the Affidavit of No Employees)

3. (Initial here) Contractor will not employ or contract with any subcontractor in connection with a covered contract unless the subcontractor is registered, authorized to use, and uses the federal work authorization program; and provides Contractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-.01 et. seq.

4. (Initial here) Contract agrees that, if Contractor employs or contracts with any sub-contractor in connection with the covered contract under the Act and DOL Rule 300-10-1-.02, that Contractor will secure from each sub-contractor at the time of the contract the sub-contractor’s name and address, the employee-number applicable to the sub-contractor, the date the authorization to use the federal work authorization program was granted to sub-contractor; the subcontractor’s attestation of the subcontractor’s compliance with the Act and Georgia Department of Labor Rule 300-10-1-.2; and the subcontractor’s agreement not to contract with sub-subcontractors unless the sub-subcontractor is registered, authorized to use, and uses the federal work authorization program; and provides subcontractor with all affidavits required by the Act and the rules and regulations issued by the Georgia Department of Labor as set forth at Rule 300-10-1-.01 et. seq.

5. (Initial here) Contractor agrees to provide the PCSD with all affidavits of compliance as required by O.C.G.A. 13-10-90 et. Seq, and Georgia Department of Labor Rule 300-10-1-.02, 300-10-1-.03, 300-10- 1-.07 and 300-10-1-.08 within five (5) business days of receipt.

6. ___ (Initial here) Vendor is a foreign company and therefore not required to provide the affidavit as required by

O.C.G.A. §13-10-90 et seq. Vendor must comply with any other laws required to perform services in the United States, including but not limited to having an appropriate visa.

Company Name: _______________________________________________________________________

CONTRACTOR AFFIDAVIT AND AGREEMENT

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. 13-10-91, and attests under oath that:

(1) The individual, firm, or corporation (“Vendor”) which is contracting with the Paulding County School District has registered with, is authorized to use, uses, and will continue throughout the contract term to use and participate in, a federal work authorization program [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603], in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91, as amended. As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is the “EEV/Basic Pilot Program” operated by the U. S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA).

(2) Vendor’s correct user identification number and date of authorization is set forth herein below.

(3) Vendor agrees that the Vendor will not employ or contract with any subcontractor(s) in connection with the physical performance of services pursuant to this contract with the Paulding County School District, unless at the time of the contract said subcontractor:

(a) is registered with and participates in the federal work authorization program;

(b) provides Vendor with a duly executed, notarized affidavit with the same affirmations, agreements, and information as contained herein and in such form as required under applicable law; and

(c) agrees to provide Vendor with notice of receipt and a copy of every subcontractor Affidavit or other applicable verification procured by subcontractor at the time of contract with the sub-contractor(s) within five (5) business days after receiving the said Affidavit or verification.

Vendor agrees to maintain records of such compliance and to provide notice of receipt and a copy of each such subcontractor Affidavit or other permissible verification to the Paulding County School District at the time the subcontractor(s) is retained to perform such service or within five (5) days after receiving the said Affidavit or verification, whichever first occurs.

(4) Vendor further agrees to and shall provide Paulding County School District with copies of all other affidavits or other applicable verification received by Vendor (i.e.: subcontractor affidavits and all other lower tiered affidavits) within five (5) days of receipt.

EEV/Basic Pilot Program User Identification Number Date of Authorization (Note: Should be a 4 to 6-digit number)

If an applicable Federal work authorization program as described above is used, other than the EEV/Basic Pilot Program, please identify the program.

Company Name / Vendor Name

BY: Signature of Authorized Officer or Agent Date

Title of Authorized Officer or Agent of Vendor

Printed Name of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _____DAY OF ___________________, 20 _____

Notary Public My Commission Expires

SUBCONTRACTOR AFFIDAVIT

By executing this affidavit, the undersigned subcontractor verifies its compliance with O.C.G.A. 13-10-91, and attests under oath that:

(1) The undersigned individual, firm or corporation (“Subcontractor”) is engaged in the physical performance of services under a contract with ________________________________________________(name of contractor), which has a contract with the Paulding County School District.

(2) Subcontractor has registered with, is authorized to use, uses, and will continue throughout the contract term to use and participate in, a federal work authorization program [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603], in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91. As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is the “EEV/Basic Pilot Program” operated by the U. S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA).

(3) Subcontractor’s correct user identification number and date of authorization is set forth herein below.

(4) Subcontractor agrees that the Subcontractor will not employ or contract with any subcontractor(s) in connection with the physical performance of services pursuant to this subcontract or the contract with the Paulding County School District, unless said subcontractor:

(a) is registered with and participates in the federal work authorization program;

(b) provides Subcontractor with a duly executed, notarized affidavit with the same affirmations, agreements, and information as contained herein and in such form as required under applicable law; and

(c) agrees to provide Subcontractor with notice of receipt and a copy of every subcontractor Affidavit or other permissible verification procured by subcontractor at the time the subcontractor(s) is retained to perform such service or within five (5) days after receiving the said Affidavit or verification, whichever first occurs.

(5) Subcontractor agrees to maintain records of such compliance and to provide notice of receipt and a copy of each such subcontractor Affidavit or other applicable verification to the Vendor at the time the subcontractor(s) is retained to perform such service or within five (5) days after receiving the said Affidavit or verification, whichever first occurs.

EEV/Basic Pilot Program User Identification Number Date of Authorization (Note: Should be a 4 to 6-digit number)

If an applicable Federal work authorization program as described above is used, other than the EEV/Basic Pilot Program, please identify the program.

Company Name / Sub-contractor Name

BY: Signature of Authorized Officer or Agent (of Subcontractor) Date

Title of Authorized Officer or Agent of Subcontractor

Printed Name of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20

AFFIDAVIT OF NO EMPLOYEES

The undersigned, in connection with a proposed contract or subcontract with the Paulding County School District for the physical performance of service in the State of Georgia (the “Contract”), hereby affirms and certifies under penalties of perjury that:

(1) I am a sole proprietor.

(2) I do not employ any other persons.

(3) I do not intend to hire any employees to perform the Contract.

(4) A true, correct and complete copy of my driver’s license is attached hereto.

(5) If at any time hereafter I determine that I will need to hire employees to satisfy or complete the physical performance of services under the Contract then before hiring any employees, I will:

(a) immediately notify the School District in writing; and

(b) register with, participate in and use, a federal work authorization program operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99- 603], in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91, as amended; and

(c) Provide the School District with all affidavits required by O.C.G.A. § 13-10-90 et seq. and Georgia Department of Labor Rule 300-10-1-.02, 300-10-1-.03, 300-10-1-.07 and 300-10-1-.08.

Print Company Name / Name of Sole Proprietor

BY: Signature of Authorized Officer/Agent Date

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE__________DAY OF , 20

[Attach a copy of driver’s license]

Construction Management-at-Risk Austin MS

This acknowledgement and agreement must be properly signed and attached to your proposal. The acknowledgement becomes a part of your proposal and without it your proposal is not complete and will be subject to rejection.

I, the undersigned, have carefully examined and fully understand the RFP 26-260511 document in its entirety and agree to conform with every requirement. I certify that I am authorized to sign this proposal for the vendor. I further acknowledge that failure to prepare, submit, or execute this proposal in the exact manner requested will be just cause to reject any or all of my proposal submission.

Withdrawals, cancellations, etc., will not be accepted unless authorization is given by the Director of Procurement Services. In the event vendors fail to comply, they may be removed from the vendors’ list.

Failure to respond using the most recent forms/information posted to the PCSD Current Solicitations website may be cause for rejection. It is the vendor’s responsibility to check the PCSD Current Solicitations website for any addenda, responses to vendor questions, or other communications, which may be necessary during the solicitation period. Vendor acknowledges and incorporates each applicable Addendum number listed below in their response:

Check all that apply: No. 1 , No. 2 , No. 3 , No. 4 , No Addenda

Prices must remain firm as specified on the award notification letter.

Company Name Representative’s Name (type or print)

Address Representative’s Signature (must be signed in ink)

City, State, and Zip Code E-Mail Address

Date Telephone Number and Extension Terms (If payment terms are not indicated, Fax Number net 30 days.)

Signing the Acknowledgement and Agreement affirms that the original Request for Proposal document has not been altered in any way

Contract Agreement

Contractor has carefully examined and fully understands the General and Special Terms and Conditions, Specifications, and other related documents included in the solicitation for the Paulding County School District and does agree to all terms and conditions by so signing this document.

The Contractor acknowledges that they, nor their principals, are not currently debarred or suspended from submitting Proposals on contracts by any agency of the State of Georgia or as defined in the Federal Acquisition Regulation (FAR) 48 C.F.R. Ch. 1 Subpart 9.4. Contractor agrees to notify PCSD if they, or their principals, become debarred or suspended while under contract with the PCSD. PCSD prohibits the awarding of a non‐procurement activity such as a sub‐award, or any other covered agreement for any program purpose with a suspended or debarred party.

It is understood that all prices quoted include delivery to the Paulding County individual schools or departments or the Paulding County Government, City of Hiram, and City of Dallas the opportunity to purchase off this agreement and should be invoiced separately as specified.

The PCSD reserves the right to reject any or all Quotes/Proposals and to accept that bid which will, in its opinion, best serve the public interest. The PCSD reserves the right to waive any technicalities and formalities in the bidding. The Contractor acknowledges that the PCSD has the right to make any inquiry or investigation it deems appropriate to substantiate or supplement information supplied by the bidder.

The PCSD reserves the option to renew the proposal as outlined in the solicitation if agreeable to both the successful vendor and the PCSD.

Signing the Contract Agreement affirms that this original document has not been altered in any way.

Representative Signature Date

Print or Type Name E‐Mail Address

Company Name Telephone Number and Extension

Address Fax Number

City, State and Zip Code

PCSD Solicitation Number (i.e. RFP 19‐102613)

Vendor Reference Form

ALL responding vendors must provide contact information for the reference letters you have provided. It is the vendor’s responsibility to provide complete and accurate reference information on the form below; completing ALL fields. Failure to do so can result in PCSD being unable to verify vendor’s past work, which may affect PCSD’s determination that the vendor is responsive and responsible. Preference may be given to references of similar size, scope and projects completed for public K-12 school districts. Do not list PCSD as a reference. PCSD reserves the right to consider past experience with vendor.

Company/Entity:

Address:

Telephone: Fax:

Contact: Contact

Name of Project/Scope of work/Delivery Method

Project Cost Project Dates

Company/Entity:

Telephone: Fax:

Telephone: Fax:

of of

Telephone: Fax:

of

Telephone: Fax:

of

Provide complete contact information for a Point of Contact DURING EVALUATION period. This person must be available to answer any questions pertaining to your response that may arise prior to award.

Company Name:

Contact Name:

Phone Number: Fax Number:

Email Address:

Non‐Collusion Affidavit

The following affidavit is to accompany the bid:

STATE OF _______________________

COUNTY OF _____________________

Owner, Partner or Officer of Firm

Company Name: _____________________________________________

Address: _____________________________________________

City, State and Zip: _____________________________________________

Being of lawful age, being first duly sworn, on oath says, that he/she is the agent authorized by the contractor to submit the attached bid. Affiant further states as contractor, that they have not been a party to any collusion among contractors in restraint or competition by agreement to bid at a fixed price or to refrain from bidding; or with any office of the Owner or any of their employees as to quantity, quality or price in the prospective contract; or any discussion between contractors and any employee of the Owner concerning exchange of money or other things of value for special consideration in submitting a sealed bid for:

FIRM NAME _____________________________________________

SIGNATURE _____________________________________________

TITLE _____________________________________________

Subscribed and sworn to before me this _____ day of ______________________, 20___.

NOTARY PUBLIC

Certificate of Non‐Discrimination

In connection with the performance of work under this contract, the bidder agrees as follows:

The bidder agrees not to discriminate against any employee or applicant for employment because of race, creed, color, sex, national origin or ancestry. The vendor shall take affirmative action to ensure that employees are treated without regard to their race, creed, color, sex, national origin or ancestry. Such action shall include, but not be limited to the following:

employment, upgrading, demotion, transfer, recruiting or recruitment, advertising, lay‐off or termination, rates of pay or other compensation and selection for training, including apprenticeship.

In the event the bidder is not in compliance with this non‐discrimination clause, the contract may be cancelled or terminated by the Paulding County School District. The Paulding County

School District may declare the bidder, ineligible for further contracts with the Paulding County

School District until satisfactory proof of intent to comply shall be made by the vendor.

The bidder agrees to include this non‐discrimination clause in any sub‐contracts connected with the performance of this agreement.

Signature: ________________________________

Printed Name: ________________________________

Date: ________________________________

Company: ________________________________

Address: ________________________________

Prompt Pay Act Affidavit

GEORGIA PROMPT PAY ACT‐The Georgia Prompt Pay Act was enacted by the General Assembly in 1994 and took effect January 1, 1995. This act requires Owners to pay contracts within 15 days of receipt of a pay request by the Owner or the Owner’s representative. If payment is not made, the Owner shall pay the contractor 1% per month interest on the delayed payment.

Additionally, the contractor must pay sub‐contractors within 10 days of receipt of payment from the Owners.

This Act is Code Section 13‐11‐1 (Georgia Laws of 1994, p. 1398 par. 4).

FIRM NAME __________________________________________________________

SIGNATURE __________________________________________________________

TITLE __________________________________________________________

Subscribed and Sworn to before me this _____ day of _____________________ 20___.

NOTARY PUBLIC

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING

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 make 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 follow-up 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 last previously submitted report by this reporting entity for this 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 first tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in Item 4 checks “subawardee”, then enter the full name, addressee, 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 or loan 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 grant, 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., “RFPDE-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 address if different from 10(a). Enter last name, first name, and middle initial.

11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.

12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution, specify the nature and value of the in-kind payment.

13. Check the appropriate box(es). Check all boxes that apply. If other, specify nature.

14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact with federal officials. Identify the federal official(s) or employee(s) contacted or the officer(s), employee(s), or member(s) of Congress that were contacted.

15. Check whether or not a Continuation Sheet(s) is attached.

16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

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 Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D.C. 20503.

FORM SPI SSMP 280F (Rev. 4/14) Bulletin No. 009-14 OSPI/Child Nutrition Services

April 2014

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See bottom for public burden disclosure.)

Approved by OMB 0348-0046

1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:

a. Contract

b. Grant

c. Cooperative agreement

d. Loan

e. Loan guarantee

f. Loan insurance

a. Bid/offer/application

b. Initial award

c. Post-award

a. Initial filing

b. Material change

For Material Change Only:

year_______quarter_______ date of last report_________

4. Name and Address of Reporting Entity: 5. If Reporting Entity In No. 4 is a Subawardee, Enter Name and Address of Prime:

Prime Subawardee

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 (if individual, last name, first name, MI):

b. Individuals Performing Services (including address if different from No. 10a) (last name, first name, MI):

11. Amount of Payment (check all that apply):

$_________________ actual planned

13. Type of Payment (check all that apply):

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other, specify: __________________________

12. Form of Payment (check all that apply):

a. cash

b. in-kind; specify: nature ___________________ value ____________________

14. Brief description of services performed or to be performed and date9s) of service including officer(s), employee(s), or member(s) contacted, for payment indicated in 11:

(Attach Continuation Sheet(s) if necessary)

15. Continuation sheet(s) attached: Yes No

16. 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 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:

Print Name:

Title:

Telephone No.: Date:

Federal Use Only: Authorized for Local Reproduction

Standard Form - LLC

FORM SPI SMP CNS 280F (Rev. 4/14)