A12_Disclosure-Loobying_Activities.pdf

PDF 269 KB Posted

Attached to
Drug Manufacturing and Formulation Program (DMFP) Federal contract opportunity
Solicitation number
75N95024R00077
Issued by
Department of Health and Human Services National Institutes of Health National Institute on Drug Abuse

About this file

Written by GovTribe AI ·

This document is a Disclosure of Lobbying Activities form required to report lobbying activities related to a covered federal action. The form collects information such as the type of federal action (e.g. contract, grant), status of the action, report type, details of the reporting entity, federal department/agency, CFDA number, federal action number, award amount, and information on lobbying registrants and individuals performing lobbying services. This form must be completed and submitted in accordance with 31 U.S.C. 1352, which requires disclosure of lobbying activities for any person who uses appropriated funds to influence or attempt 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. The completed form will be reported to Congress semi-annually and made available for public inspection.

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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:

Type of Federal Action: 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. This field is required.

Type of Federal Action is required: 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. * Status of Federal Action:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Status of Federal Action is required: Identify the status of the covered Federal action.

3. * Report Type:

Report Type: 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 previously submitted report by this reporting entity for this covered Federal action. This field is required.

For Material Change Only:

year quarter date of last report

4. Name and Address of Reporting Entity:

Reporting Entity: 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 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 limited to subcontracts, subgrants and contract awards under grants. This field is required.

Reporting Entity is required: 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 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 limited to subcontracts, subgrants and contract awards under grants.

Tier if known:

* Name

* Street 1 Street 2

* City State Zip Congressional District, if known:

Congressional District, if known:

* Name

* City State

* Street 1 Street 2 Zip

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) Contract InitialAward InitialFiling Y: Yes

XDPFirstField:
Mandatory:
Disclosure Statement: Click the button to read the "Review Public Burden Disclosure Statement".:
Type of Federal Action: 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. This field is required.

Contract: Click if the Type of Federal Action is a contract.:

Type of Federal Action: 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. This field is required.

Grant: Click if the Type of Federal Action is a grant.:

Type of Federal Action: 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. This field is required.

Cooperative Agreement: Click if the Type of Federal Action is a cooperative agreement.:

Type of Federal Action: 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. This field is required.

Loan: Click if the Type of Federal Action is a loan.:

Type of Federal Action: 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. This field is required.

Loan Guarantee: Click if the Type of Federal Action is a loan guarantee.:

Type of Federal Action: 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. This field is required.

Loan Insurance: Click if the Type of Federal Action is a loan insurance.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Bid, Offer, Application: Click if the Status of Federal Action is a bid, an offer or an application.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Initial Award: Click if the Status of Federal Action is an initial award.:

Status of Federal Action: Identify the status of the covered Federal action. This field is required.

Post Award: Click if the Status of Federal Action is a post-award.:

Report Type: 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 previously submitted report by this reporting entity for this covered Federal action. This field is required.

Initial Filing: Click if the Report Type is a initial filing.:

Report Type: 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 previously submitted report by this reporting entity for this covered Federal action. This field is required.

Material Change: Click if the Report Type is a material change.:

Year: If this is a follow up report caused by a material change to the information previously reported, enter the year in which the change occurred.:
Quarter: If this is a follow up report caused by a material change to the information previously reported, enter the quarter in which the change occurred.:
Date of last report: Enter the date of the previously submitted report by this reporting entity for this covered Federal action.:
ReportingEntityEntityType:
Reporting Entity: 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 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 limited to subcontracts, subgrants and contract awards under grants. This field is required.

Prime: Click to designate the organization filing the report as the Prime Federal recipient.:

SubAwardee: Click to designate the organization filing the report as the SubAwardee Federal recipient. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.:
ReportEntityType:
Tier: Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. :
Reporting Entity Organization Name: Enter the name of reporting entity. This field is required.:
Street 1: Enter the first line of the street address for the Reporting Entity. This field is required.:
Street 2: Enter the second line of the street address for the Reporting Entity.:
City: Enter the city of the Reporting Entity. This field is required.:
State: Select the state for the Reporting Entity's address from this pull down menu.:
Zip / Postal Code: Zip Code (or ZIP+4) of the Reporting Entity.:
Congressional District: If known, the Congressional District of the reporting entity. Should be numeric characters.:
Section5Text:
Prime Organization Name: If the organization filing the report in item 4, checks "Subawardee", enter the full name of the prime Federal recipient.:
Street 1: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:
Street 2: If the organization filing the report in item 4, checks "Subawardee", enter the address of the prime Federal recipient.:
City: If the organization filing the report in item 4, checks "Subawardee", enter the city of the prime Federal recipient.:
State: If the organization filing the report in item 4, checks "Subawardee", select the appropriate state from this pull down menu.:
Zip / Postal Code: If the organization filing the report in item 4, checks "Subawardee", enter the zip code.:
Congressional District: If the organization filing the report in item 4, checks "Subawardee", enter the Congressional District of the prime Federal recipient, if known. Should be numeric characters.:
EntityType: Prime
Federal Department/Agency: Enter the name of the Federal Department or Agency making the award or loan commitment. This field is required.:
CFDA/Program Title: 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. :
CFDA Number: 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.:
Federal Action Number: 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".:
Award Amount: 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 of the prime entity identified in item 4 or 5.:
Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Lobbying Registrant.:
First Name: Enter the first name of Lobbying Registrant. This field is required.:
Middle Name: Enter the middle name of Lobbying Registrant.:
Last Name: Enter the last name of Lobbying Registrant. This field is required.:
Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Lobbying Registrant.:
Street 1: Enter the first line of street address for the Lobbying Registrant.:
Street 2: Enter the second line of street address for the Lobbying Registrant.:
City: Enter the city of the Lobbying Registrant.:
State: Select the appropriate state of the Lobbying Registrant.:
Zip / Postal Code: Enter the Zip Code (or ZIP+4) of the Lobbying Registrant.:
DataEntered1:
Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Individual Performing Services.:
First Name: Enter the first name of the Individual Performing Services. This field is required.:
Middle Name: Enter the middle name of the Individual Performing Services.:
Last Name: Enter the last name of the Individual Performing Services. This field is required.:
Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Individual Performing Services.:
Street 2: Enter the second line of street address for the Individual Performing Services.:
City: Enter the city of the Individual Performing Services. :
State: Select the state for the address of the Individual Performing Services from this pull down menu.:
Zip / Postal Code: Enter the Zip Code (or ZIP+4) of the Individual Performing Services.:
Street 1: Enter the first line of street address for the Individual Performing Services.:
DataEntered2:
Prefix: Enter the prefix (e.g., Mr., Mrs., Miss), if appropriate, for the Certifying Official.:
First Name: Enter the first name of Certifying Official. This field is required.:
Middle Name: Enter the middle name of the Certifying Official.:
Last Name: Enter the last name of the Certifying Official. This field is required.:
Suffix: Enter the suffix (e.g., Jr. Sr., PhD), if appropriate, for the Certifying Official.:
Title: Enter the title of the Certifying Official.:
Telephone Number: Enter the telephone number of the certifying official.:
LastField:
Signature: Enter the Signature. This field is required.

Date: Enter the date signed. Enter in the format mm/dd/yyyy. This field is required.:

File details come from the government source that posted it. Updated .