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3T5-030-35
<br /> PROCUREMEffr
<br /> 04714
<br /> Pape1 o.i
<br /> INSTRUCTIONS FOR COMPLETION OF SF-LLL,DISCLOSURE OF LOBBYING ACTIVITIES
<br /> This disclosure form shall be completed by the reporting entity,whether subawardee or prime Federat recipient,at the
<br /> initiation or receipt of a covered Federal action,or a material change to a previous filing,pursuant to title 31 U.S_C.
<br /> section 1352.The filing of a form is required for each payment or agreement to make payment to any lobbying entity for
<br /> influencing or attempting to influence an officer or employee of any agency,a Member of Congress,an officer or
<br /> employee of Congress,or an employee of a Member of Congress in connection with a covered Federal action-Complete
<br /> all items that apply for both the initial filing and material change report.Refer to the implementing guidance published by
<br /> the Office of Management and Budget for additional information.
<br /> 1. Identify the type of covered Federal action for which lobbying activity is andfor has been secured to influence the
<br /> outcome of a covered Federal action.
<br /> 2_ Identify the status of the covered Federal action.
<br /> 3- Identify the appropriate classification of this report_If this is a followup report caused by a material change to the
<br /> information previously reported,enter the year and quarter in which the change occurred.Enter the date of the last
<br /> previously submitted report by this reporting entity for this covered Federal action.
<br /> 4- Enter the fullname,address,city,State and zip code of the reporting entity.Include Congressional District,if
<br /> known-Check the appropriate classification of the reporting entity that designates if it is,or expects to be,a prime
<br /> or subaward recipient Identify the tier of the subawardee,e.g.,the first subawardee of the prime is the 1st tier.
<br /> Subawards include but are not limited to subcontracts,subgrants and contract awards under grants_
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<br /> 5_ If the organization 6fing the report in item 4 checks"Subawardee,"then enter the full name,address,city,State I
<br /> and zip code of the prime Federal recipient.Include Congressional District,if known_
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<br /> 6- Enter the name of the Federal agency making the award or loan commitment Include at least one organizational f
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<br /> level below agency name,if known_For example,Department of Transportation,United States Coast Guard-
<br /> 7- Enter the Federal program name or description for the covered Federal action(item 1).If known,enter the full {
<br /> Catalog of Federal Domestic Assistance(CFDA)number for grants,cooperative agreements,loans,and loan
<br /> commitments_
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<br /> 8_ Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g-, ;
<br /> Request for Proposal(RFP)number,Invitation for Bid(IFB)number;grant announcement number,the contract,
<br /> grant,or loan award number-,the applicationtproposal control number assigned by the Federal agency)-Include
<br /> prefixes,e_g_,"RFP-DE-90-001." l
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<br /> 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,enter
<br /> the Federal amount ofthe awardiloan commitment for the prime entity identified in item 4 or 5-
<br /> 10- (a)Enter:the full name,address,city,State and zip code of the lobbying registrant under the Lobbying
<br /> Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal
<br /> action_
<br /> (b)Enter the full names of the fndividual(s)performing services,and include full address if different from 10(a)-
<br /> Enter Last Name,First Name,and Middle Initial(MI).
<br /> 11. The certifying official shall sign and date the farm,print hislher name,title,and telephone number_
<br /> According to the Paperwofic Reduction Ad,as amended,nay persons are required to respond to a.collection of information unless it displayss.
<br /> valid OMB Control Nianber.The valid OMS con1ml numberforthis infomution erection is OMB No.03484)4348.Public repotting burdenforthis,
<br /> cotlection oretfocmation is estimated to average to minutes perresponse,including tirne forreviewirg ia5uuctions.searching e3-vs ng data sources,
<br /> gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments,regarding the burden
<br /> estimate or any other aspect of this cc,(Wc ion of inl`cx c tion,inducting suggestions for reducing this burden,to the Office Df Management and
<br /> Budget Paperwork Reduction Project(03484)0481,Washington.DC 205113.
<br /> 00474-3
<br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1049_8th St Sidewalk Improvements(58th Ave to 21st Court)\Admim\bid
<br /> documents\LAP Documents\00474-CERTIFICATION for DISCLOSURE OF LOBBYING ACTIVITIES.doc
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