Attachment_11.pdf

Attachment 12

Approved by OM I3 0348-0046

Disclosure of Lobbying Activities Colnplete this form to disclose lobbying activities pursuant lo 3 1 U.S.C. 1352

(See reverse for public burden disclosure) I I I

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. bidiofferlapplication

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

I I

I 1 CFDA Number, ifapplicable: -

4. Name and Address of Reporting Entity:

- Prime Subawardee

Tier , if K n o w :

Congressional District, if known:

6. Federal DepnrtmentlAgency:

I

7. Federal Action Number, fknown: j 9. Award Amourit, ifknol-vn:

I 1

5. lf Reporting Entity in No. 4 is Subswardee, Enter Name and Address of Prime:

Congressional District, if known:

7. Federal Program Name/Description:

I

10. a. Name and Address of Lobbying Registrant (findividzial, losr name,firsr name, MI):

Federal Use Only s

b. Individuals Performing Services (including udclress f differen! from No. IOU)

(last nante, first nante, MI):

1 I . 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 sllall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Authorized for Local Reproduction Standard Forni - LLL (Rev. 7-97)

S i g ~ a t u r e :

Print Name:

Title: - '

No*: Date:

Attachment 1 2

INSTRUCTIONS FOR COIMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVlTlES

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 : I 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 Managenlent and Budget for additional information.

1 . Identify the type of covered Federal action for which lobbying activity is and!or has been secured LO influence the outcome of a covered Federal action.

Identify the status of the covered Federal action.

ldentify 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 last previously submitted report by this reporting entity for this covered Federal action.

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 I st iier.

Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

if the organization filing the report in item 4 checks "Subawardee," then e,nter the full name. address, city, State and zip code of the prime Federal recipient. Include Congressional District, if known.

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.

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.

Enter the most appropriate Federal identifying number available for the Federal action identified in item I (e.g., Request for Proposal (RFP) number; Invitations for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assig~led by the Federal agency). Included prefixes, e.g., "RFP-DE-90-00 I ."

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.

(a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 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 1 O(a).

Enter Last Name, First Name, and Middle Initial (MI).

The certifying official shall sign and date the form, print hisher name, title, and telephone number.

According to the ~ a ~ c n v o r k Reduction Act, as amended, no persons are required to respond to a collection oTinforniation unless it displays a valid 0M.B control Number. The valid OMB control number Ibr this inforn~ation collection is OMB No. 0348-0046. I'ublic reporting burden for this collection of information is estimated to average 10 minutes per response. including h i e for reviewing instructions.

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of infjrmation.

Send comments regarding the burden estimate or any other aspect ot'this collection of information, including suggestions for reducing this burden, to the Oflice of Management and Budget, Papenvork Reduction Project (0348-0046). Washington, DC 20503 a-