J.1 Disclosure of Lobbying Activities.pdf
PDF 2 MB Posted
- Attached to
- HUMAN FACTORS Federal contract opportunity
- Solicitation number
- 693JJ924R000031
About this file
This document is the Standard Form LLL - Disclosure of Lobbying Activities, which is used to disclose lobbying activities conducted to influence the outcome of a covered federal action. It requires the reporting entity to provide details such as the type of federal action, the status of the action, the report type, the reporting entity information, the federal department/agency involved, the federal program details, the federal action number, the award amount (if known), and the details of the lobbying registrant and the individual performing the lobbying services.
The related federal contract opportunity is for HUMAN FACTORS research to be conducted on behalf of the National Highway Traffic Safety Administration (NHTSA), within the Department of Transportation. The solicitation number is 693JJ924R000031, and the objective is to support NHTSA's mission of improving safety on U.S. roads by investigating how drivers and other road users perform as a system component in the safe operation of vehicles. The contractor will be required to carry out rigorous and innovative motor vehicle safety-related research.
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Standard Form LLL - Disclosure of Lobbying Activities pward D:20061124112418- 05'00' D:20061124112418- 05'00'
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 OMB Control Number: 4040-0013 Expiration Date: 2/28/2025
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:
STANDARD FORM LLL (REV. 7/1997)
Authorized for Local Reproduction Contract BidOffer 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.:
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