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' STATE OF FLORIDA DEPARTIAENr OF TWNSPOrZTATION 37543D-34 <br /> DISCLOSURE OF LOBBYING ACTIVITIES PROCUREMENT <br /> ams <br /> Is this form appZmplete <br /> le to your fi mn? <br /> YES❑ NO <br /> If no,then pleas section 4 <br /> below foe"Prime' <br /> 1.Type of Federal Action: 2.Status of Federal Action: 3.Report Type: <br /> a_contract a_bidloffer/application a initial filing <br /> b_grant b_initial award b-material change <br /> c_cooperative agreement c_post-award For Material Change Only: <br /> d_loan Year. Quarter_ <br /> e.loan guarantee Date of last report <br /> f.loan insurance (mm/dd/yyyy) <br /> 4_Name and Address of Reporting Entity 5.If Reporting Entity in No.4 is a Subawardee,Enter Name and <br /> ❑ Prime ❑ Subawardee Address of Prime: <br /> Tier if known. <br /> Con ressiona4 District,if known_4c Congressional.District,if known: <br /> 6.Federal Department/Agency: 7.Federal Program Name/Description: <br /> CFDA Number,if applicable: <br /> 8.Federal Action Number,if known: 9.Award Amount,if known: <br /> 10.a.Name and Address of Lobbying Registrant b.Individuals Performing Services(including address if <br /> (if individual,last name,fust name,M4: different from No_ 1Qa) <br /> (last name,first name,M4- <br /> 11. Information requested through ttis form is authorized by title 31 <br /> U.S.C.section 1352 This disclosure oaf lobbying activities is a Signature: <br /> material representation of fact upon wbich reliance was placed `� �+ <br /> by She Her above when this transaction was made or entered print Name: ) y6 s <br /> into.This disclosure Is required pursuant to 31 US_e.1352 <br /> This information will be available fig public inspeclion_Any <br /> person who fails to Ere the required disclosure shalt he subject Title. .-C � <br /> to a civil penalty of not less than$ DOO and not morethan AlA/f Date(mn>Idd/ <br /> $100.000 foreach such failure. Telephone No ((A- yyyy): . ,k <br /> � <br /> _} '�c" <br /> edeial Use OnlAuthorized for Loral Reproduction <br /> ,.K. Standard Form LLL(Rev-7-9 <br /> 00474-2 <br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1049_8th St Sidewalk Improvements(58th Ave to 21st Court)1Admim\bid <br /> documentS\LAP Documents\00474-CERTIFICATION for DISCLOSURE OF LOBBYING ACTIVITIES.doc <br /> J <br />