W91278-17-R-0048_Amendment_0001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE PAGE OF PAGES

2. AMENDMENT/MODIFICATION NO. 3. EFFECTIVE 4. REQUISITION/PURCHASE 5. PROJECT NO. (If applicable)

W91278-17-R-0048-0001 05/03/2017 W 31XNJ70331260

6. ISSUED BY CODE W91278 7. ADMINISTERED BY(If other than item 6)

CODE

US ARMY ENGINEER DISTRICT, MOBILE

CONTRACTING DIVISION (CESAM-CT-C)

(109 ST. JOSEPH ST. 36602) P.O. BOX 2288

MOBILE, AL 36628-0001

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP code) 9A. AMENDMENT OF SOLICITATION

NO.

W91278-17-R-0048

9B. DATED (SEE ITEM 11)

04/14/2017

10A. MODIFICATION OF

CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in item 14. The hour and date specified for receipt of Offers is extended, is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (if required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO AUTHORITY OF FAR 43.103(b)

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible)

The subject solicitation IDIQ CONTRACT FOR RENTAL OF CONSTRUCTION EQUIPMENT WITH OPERATORS FOR DISPOSAL AREA MAINTENANCE

ACTIVITIES FOR MOBILE HARBOR, ALABAMA

Is modified in the following: REFER TO THE ENCLOSED TABLE OF CONTENTS Changes as additions are identified by BOLD ITALICS text

NOTE: THE RECEIPT OF PROPOSAL DATE IS NOT REVISED BY THIS AMENDMENT. REFER TO THE ENCLOSED SF1442, SOLICITATION, OFFER &

AWARD FORM.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICE (Type or print)

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

BY

(Signature of contracting officer)

16C. DATE SIGNED

NSN 7540-01-152-8070 30-105 STANDARD FORM 30 (REV. 10-83)

PREVIOUS EDITION UNUSABLE Prescribed by GSA

W91278-17-R-0048 IDIQ CONTRACT FOR RENTAL OF CONSTRUCTION EQUIPMENT

WITH OPERATORS FOR DISPOSAL AREA MAINTENANCE

ACTIVITIES FOR MOBILE HARBOR, ALABAMA

Table of Contents Page 1

PROJECT TABLE OF CONTENTS

CHECKLIST FOR PREPARATION OF OFFERS

BIDDING REQUIREMENTS

Contract Clauses

STANDARD FORM 1442 - SOLICITATION, OFFER, AND AWARD

BIDDING SCHEDULE

STANDARD FORM 24 - BID BOND

STANDARD FORM 28 - AFFIDAVIT OF INDIVIDUAL SURETY

STANDARD FORM LLL - DISCLOSURE OF LOBBYING ACTIVITIES

00100 INSTRUCTIONS TO BIDDERS

00 11 00 TRADE-OFF BEST VALUE SOURCE SELECTION

(Proposal Submission Requirements and Instructions)

00 12 00 TRADE-OFF BEST VALUE SOURCE SELECTION

(Evaluation of Proposals and Basis of Award)

00600 REPRESENTATIONS & CERTIFICATIONS

00700 CONTRACT CLAUSES

CESAM FORM 1151, PROMPT PAYMENT CERTIFICATION

00800 SPECIAL CONTRACT REQUIREMENTS

DIVISION 01 - GENERAL REQUIREMENTS

01 00 00 ADDITIONAL SPECIAL CONTRACT REQUIREMENTS

PROJECT SIGNS

WAGE RATES

01 10 10 OUTLINE OF THE TASK ORDER PROCESS

01 33 00 SUBMITTAL PROCEDURES

SUBMITTAL REGISTERS

ENGINEERING FORM 4025R

01 35 26 GOVERNMENTAL SAFETY REQUIREMENTS

01 42 00 SOURCES FOR REFERENCE PUBLICATIONS

01 45 00.00 10 QUALITY CONTROL

SAM FORM 696

01 45 00.10 10 QUALITY CONTROL SYSTEM (QCS)

01 57 20.00 10 ENVIRONMENTAL PROTECTION

End of Project Table of Contents

(See ).

SOLICITATION, OFFER,

AND AWARD

(Construction, Alteration, or Repair) W91278-17-R-0048 IMPORTANT - The "offer" section on the reverse must be fully completed by offeror.

9. FOR INFORMATION

CALL:

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid and "bidder".

SOLICITATION

1. SOLICITATION NUMBER

5. REQUISITION/PURCHASE REQUEST NUMBER

CODE

6. PROJECT NUMBER

8. ADDRESS OFFER TO

4. CONTRACT NUMBER

7. ISSUED BY

10. THE GOVERNMENT REQUIRES PERFORMANCE OF THE WORK DESCRIBED IN THESE DOCUMENTS (Title, identifying number, date)

11. The contractor shall begin performance within

12a. THE CONTRACTOR MUST FURNISH ANY REQUIRED PERFORMANCE AND PAYMENT BONDS?

(If "YES", indicate within how many calendar days after award in Item 12b.)

13. ADDITIONAL SOLICITATION REQUIREMENTS:

a. Sealed offers in original and

b. An offer guarantee

c. All offers are subject to the (1) work requirements, and (2) other provisions and clauses incorporated in the solicitation in full text or by reference.

d. Offers providing less than

STANDARD FORM 1442 (REV. 8/2014)

Prescribed by GSA - FAR (48 CFR) 53.236-1(d) calendar days for Government acceptance after the date offers are due will not be considered and will be rejected.

is, is not required.

local time May 18, 2017 containing offers shall be marked to show the offeror's name and address, the solicitation number, and the date and time offers are due.

(date). If this is a sealed bid solicitation, offers will be publicly opened at that time. Sealed envelopes copies to perform the work required are due at the place specified in Item 8 by (hour) award, YES NO notice to proceed. This performance period is mandatory negotiable.

calendar days and complete it within calendar days after receiving

a. NAME b. TELEPHONE NUMBER (Include area code) (NO COLLECT CALLS)

12b. CALENDAR DAYS

2. TYPE OF SOLICITATION

SEALED BID (IFB)

NEGOTIATED (RFP)

3. DATE ISSUED PAGE OF PAGES

U.S. ARMY ENGINEER DISTRICT, MOBILE

CONTRACTING DIVISION (CESAM-CT-C)

(109 ST. JOSEPH ST. 36602) P.O. BOX 2288

MOBILE, AL 36628-0001

IDIQ CONTRACT FOR RENTAL OF CONSTRUCTION EQUIPMENT WITH OPERATORS FOR DISPOSAL

AREA MAINTENANCE ACTIVITIES FOR MOBILE HARBOR, ALABAMA

*Block 11.: Refer to Checklist for Preparation of Offers, paragraph 8 for the term of the contract.

**Block 13.A.: Refer to Section 00 11 00, for number of copies to submit.

SAME AS BLOCK 7

IF HAND CARRIED, DELIVER TO

PLANS ROOM 1009

W31XNJ70331260

W91278

Nathan J. Fry, Contract Specialist (251) 690-2536 nathan.j.fry@usace.army.mil

104/12/2017

17. The offeror agrees to perform the work required at the prices specified below in strict accordance with the terms of this solicitation, if this offer is accepted calendar days after the date offers are due. (Insert any number equal to or greater than the minimum requirement by the Government in writing within stated in Item 13d. Failure to insert any number means the offeror accepts the minimum in Item 13d.)

OFFER (Must be fully completed by offeror)

AMOUNTS

18. The offeror agrees to furnish any required performance and payment bonds.

19. ACKNOWLEDGMENT OF AMENDMENTS

(The offeror acknowledges receipt of amendments to the solicitation -- give number and date of each)

AMENDMENT

NUMBER

DATE.

AWARD (To be completed by Government)

CONTRACTING OFFICER WILL COMPLETE ITEM 28 OR 29 AS APPLICABLE

14. NAME AND ADDRESS OF OFFEROR (Include ZIP Code)

CODE FACILITY CODE

15. TELEPHONE NUMBER (Include area code)

16. REMITTANCE ADDRESS (Include only if different than Item 14.)

20a. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER (Type or print)

21. ITEMS ACCEPTED:

22. AMOUNT

26. ADMINISTERED BY

30a. NAME AND TITLE OF CONTRACTOR OR PERSON AUTHORIZED TO SIGN (Type or print)

31c. DATE

STANDARD FORM 1442 (REV. 8/2014) BACK

31b. UNITED STATES OF AMERICA

BY

31a. NAME OF CONTRACTING OFFICER (Type or print)

29. AWARD (Contractor is not required to sign this document.) Your offer on this solicitation is hereby accepted as to the items listed. This award consummates the contract, which consists of (a) the Government solicitation and your offer, and (b) this contract award. No further contractual document is necessary.

30b. SIGNATURE 30c. DATE

28. NEGOTIATED AGREEMENT (Contractor is required to sign this document and return and deliver all items or perform all work requirements identified on this form and any continuation sheets for the consideration stated in this contract. The rights and obligations of the parties to this contract shall be governed by (a) this contract award, (b) the solicitation, and (c) the clauses, representations, certifications, and specifications incorporated by reference in or attached to this contract.

copies to issuing office.) Contractor agrees to furnish

24. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

23. ACCOUNTING AND APPROPRIATION DATA

ITEM 25. OTHER THAN FULL AND OPEN COMPETITION PURSUANT TO

27. PAYMENT WILL BE MADE BY

10 U.S.C. 2304(c) ( ) 41 U.S.C. 3304(a) ( )

20b. SIGNATURE 20c. OFFER DATE

BID BOND

( See instructions on reverse)

DATE BOND EXECUTED (Must not be later than bid opening date) OMB Number: 9000-0045

Expiration Date: 6/30/2016 Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the 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 this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to the FAR Secretariat (MVR), Federal Acquisition Policy Division, GSA, Washington, DC 20405.

PRINCIPAL (Legal name and business address) TYPE OF ORGANIZATION ("X" one)

INDIVIDUAL

JOINT VENTURE

PARTNERSHIP

CORPORATION

STATE OF INCORPORATION

SURETY(IES) (Name and business address)

PERCENT

OF BID

PRICE

PENAL SUM OF BOND

AMOUNT NOT TO EXCEED

MILLION (S) THOUSAND(S) HUNDRED(S) CENTS

BID IDENTIFICATION

BID DATE

FOR (Construction, supplies, or Services)

INVITATION NO.

OBLIGATION

We, the Principal and Surety (ies) are firmly bound to the United States of America (hereinafter call the Government) in the above penal sum. For payment of the penal sum, we bind ourselves, our heirs, executors, administrators, and successors, jointly and severally. However, where the sureties are corporations acting as co-sureties, we, the Sureties, bind ourselves in such sum "jointly and severally" as well as "severally" only for the purpose of allowing a joint action or actions against any or all of us. For all other purposes, each Surety binds itself, jointly and severally with the Principal, for the payment of the sum shown opposite the name of the Surety. If no limit of liability is indicated, the limit or liability is the full amount of the penal sum.

CONDITIONS:

The principal has submitted the bid identified above.

THEREFORE:

The above obligation is void if the Principal - (a) upon acceptance by the Government of the bid identified above, within the period specified therein for acceptance (sixty (60) days if no period is specified), executes the further contractual documents and gives the bond(s) required by the terms of the bid as accepted within the time specified (ten (10 days if no period is specified) after receipt of the forms by the principal; or (b) in the event of failure to executes such further contractual documents and give such bonds, pays the Government for any cost of procuring the work which exceeds the amount of the bid.

Each surety executing this instrument agrees that its obligations is not impaired by any extension(s) of the time for acceptance of the bid that the principal may grand to the Government. Notice to the surety (ies) of extensions (s) are waived. However, waiver of the notice applies only to extensions aggregating not more than sixty (60) calendar days in addition to the periods originally allowed for acceptance of the bid.

WITNESS

The principal and Surety (ies) executed this bid bond and affixed their seals on the above date.

PRINCIPAL

SIGNATURE(S)

NAME(S) &

TITLE(S)

(Typed)

1.

1. 2.

2.

3.

3.

(Seal) (Seal) (Seal) Corporate Seal

INDIVIDUAL SURETY(IES)

SIGNATURE(S)

NAME(S)

(Typed)

1.

1.

2.

2.

(Seal) (Seal)

CORPORATE SURETY(IES)

SU

R

ET

Y

A

NAME &

ADDRESS

STATE OF INC. LIABILITY LIMIT ($)

SIGNATURE(S)

NAME(S) &

TITLE(S)

(Typed)

1.

1.

2.

2. Corporate Seal

AUTHORIZED FOR LOCAL REPRODUCTION

Pervious edition is usable

STANDARD FORM 24 (REV. 10/1998)

Prescribed by GSA - FAR (48 CFR) 53.228(a)

SU

R

ET

Y

B

NAME &

ADDRESS

STATE OF INC. LIABILITY LIMIT ($)

SIGNATURE(S)

NAME(S) &

TITLE(S)

(Typed)

1.

1.

2.

2. Corporate Seal

Corporate Seal

LIABILITY LIMIT ($)STATE OF INC.

2.

2.

1.

1.NAME(S) &

TITLE(S)

(Typed)

SIGNATURE(S)

NAME &

ADDRESS

SU

R

ET

Y

C

Corporate Seal

LIABILITY LIMIT ($)

2.

2.

STATE OF INC.

1.

1.

NAME(S) &

TITLE(S)

(Typed)

SIGNATURE(S)

NAME &

ADDRESS

SU

R

ET

Y

D

Corporate Seal

LIABILITY LIMIT ($)

2.

2.

STATE OF INC.

1.

1.

NAME(S) &

TITLE(S)

(Typed)

SIGNATURE(S)

NAME &

ADDRESS

SU

R

ET

Y

E

Corporate Seal

LIABILITY LIMIT ($)

2.

2.

STATE OF INC.

1.

1.

NAME(S) &

TITLE(S)

(Typed)

SIGNATURE(S)

NAME &

ADDRESS

SU

R

ET

Y

F

Corporate Seal

LIABILITY LIMIT ($)

2.

2.

STATE OF INC.

1.

1.

NAME(S) &

TITLE(S)

(Typed)

SIGNATURE(S)

NAME &

ADDRESS

SU

R

ET

Y

G

INSTRUCTIONS

1. This form is authorized for use when a bid guaranty is required. any deviation from this form will require the written approval of the Administrator of General Services.

2, Insert the full legal name and business address of the Principal in the space designated "Principal" on the face of the form. An authorized person shall sign the bond. Any person signing in a representative capacity (e.g., ab attorney-in-fact) must furnish evidence of authority if that representative is not a member of the firm, partnership, or joint venture, or an officer of the corporation involved.

3. The bond may express penal sum as a percentage of the bid price. In these cases, the bond may state a maximum dollar limitation (e.g., 20% of the bid price but the amount not to exceed dollars).

4. (a) Corporation executing the bond as sureties must appear on the Department of the Treasury's list of approved sureties and must act within the limitation listed therein. where more than one corporate surety is involved, their names and address shall appear in the spaces (Surety A, Surety B, etc.) headed "CORPORATE SURETY (IES)." In the space designed "SURETY (IES)" on the face of the form, insert only the letter identification of the sureties.

(b) Where individual sureties are involved, a completed Affidavit of Individual surety (Standard Form 28), or each individual surety, shall accompany the bond. The Government may require the surety to furnish additional substantiating information concerning its financial capability.

5. Corporations executing the bond shall affix their corporate seals. Individuals shall execute the bond opposite the word " Corporate Seal";

and shall affix an adhesive seal if executed in Maine, New Hampshire, or any other jurisdiction requiring adhesive seals.

6. Type the name and title of each person signing this bond in the space provided.

7. In its application to negotiated contracts, the terms "bid" and "bidder" shall include "proposal" and "Offeror."

STANDARD FORM 24 (REV. 10/1998) BACK

AFFIDAVIT OF INDIVIDUAL SURETY

(See instructions on reverse)

STATE OF

COUNTY OF

SS.

I, the undersigned, being duly sworn, depose and say that I am: (1) the surety to the attached bond(s); (2) a citizen of the United States; and of full age and legally competent. I also depose and say that, concerning any stocks or bonds included in the assets listed below, that there are no restrictions on the resale of these securities pursuant to the registration provisions of Section 5 of the Securities Act of 1933. I recognize that statements contained herein concern a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious or fraudulent statement may render the maker subject to prosecution under Title 18, United States Code Sections 1001 and 494. This affidavit is made to induce the United States of America to accept me as surety on the attached bond.

1. NAME (First, Middle, Last) (Type or Print) 2. HOME ADDRESS (Number, Street, City, State, ZIP Code)

3. TYPE AND DURATION OF OCCUPATION 4. NAME AND ADDRESS OF EMPLOYER (If Self-employed, so State)

5. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED

(Number, Street, City, State, ZIP Code)

6. TELEPHONE NUMBER

HOME -

BUSINESS -

7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND:

(a) Real estate (Include a legal description, street address and other identifying description; the market value; attach supporting certified documents including recorded lien; evidence of title and the current tax assessment of the property. For market value approach, also provide a current appraisal.)

(b) Assets other than real estate (describe the assets, the details of the escrow account, and attach certified evidence thereof).

8. IDENTIFY ALL MORTGAGES, LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS INCLUDING REAL ESTATE TAXES DUE AND

PAYABLE.

9. IDENTIFY ALL BONDS, INCLUDING BID GUARANTEES, FOR WHICH THE SUBJECT ASSETS HAVE BEEN PLEDGED WITHIN 3 YEARS PRIOR TO THE DATE OF

EXECUTION OF THIS AFFIDAVIT.

DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.

10. SIGNATURE 11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate)

12. SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:

a. DATE OATH ADMINISTERED

MONTH DAY YEAR

b. CITY AND STATE (Or other jurisdiction)

Official Sealc. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH

(Type or print)

d. SIGNATURE e. MY COMMISSION

EXPIRES

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is not usable

STANDARD FORM 28 (REV. 6/2003)

Prescribed by GSA-FAR (48 CFR) 53.228(e)

Public reporting burden for this collection of information is estimated to average 0.4 hours per response, including the 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Regulatory Secretariat (M1V1CB), Office of Acquisition Policy, GSA, Washington, DC 20405.

OMB Control Number: 9000-0001 Expiration Date: 1/31/2018

INSTRUCTIONS

1. Individual sureties on bonds executed in connection with Government contracts must complete and submit this form with the bond. (See 48 CFR 28.203, 53.228(e).) The surety must have the completed form notarized.

2. No corporation, partnership, or other unincorporated association or firm, as such, is acceptable as an individual surety. Likewise, members of a partnership are not acceptable as sureties on bonds that a partnership or an association, or any co-partner or member thereof, is the principal obligor. However, stockholders of corporate principals are acceptable provided (a) their qualifications are independent of their stockholdings or financial interest therein, and (b) that the fact is expressed in the affidavit of justification. An individual surety will not include any financial interest in assets connected with the principal on the bond that this affidavit supports.

3. United States citizenship is a requirement for individual sureties for contracts and bonds when the contract is awarded in the United States. However, when the Contracting Officer is located in an outlying area or a foreign country, the individual surety is only required to be a permanent resident of the area or country in which the contracting officer is located.

4. All signatures of the affidavit submitted must be originals. Affidavits bearing reproduced signatures are not acceptable. An authorized person must sign the bond. Any person signing in a representative capacity (e.g., an attorney-in-fact) must furnish evidence of authority if that representative is not a member of a firm, partnership, or joint venture, or an officer of the corporation involved.

STANDARD FORM 28 (REV. 6/2003) BACK

DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

(See reverse for public burden disclosure.)

1. Type of Federal Action:

a.

b.

c.

d.

e.

f.

contract grant cooperative agreement loan loan guarantee loan insurance

2. Status of Federal Action:

a.

b.

c.

bid/offer/application initial award post-award

3. Report Type:

a.

b.

initial filing material change

For Material Change Only:

year quarter date of last report

4. Name and Address of Reporting Entity:

Congressional District, if known:

Prime Subawardee Tier , if known:

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

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):

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

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

$ actual planned

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

a.

b.

cash in-kind; specify: nature value

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

a.

b.

c.

d.

e.

f.

retainer one-time fee commission contingent fee deferred other; specify:

14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment indicated in Item 11:

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

15. Continuation Sheet(s) SF-LLL-A attached: Yes No

Information requested through this form is authorized by title 31 U.S.C section 1352. This disclosure of lobbyig activities is a materia 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 - LLL

Approved by OM 0348-0046

16.

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

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. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. 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.

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.

Identify the status of the covered Federal action.

Identify 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 1st tier.

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 enter 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 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.”

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 entity engaged by the reporting entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individuals(s) performing services, and include full address if different from 10 (a).

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

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.

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.

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

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

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

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.

DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Authorized for Local Reproduction Standard Form - LLL-A

Approved by OM 0348-0046

Reporting Entity: Page of

*U.S. G.P.O. 1990-260-708:00012