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TATE OF FLG1-UDA FPARTAIQ•IT OF Tr'2MSPORTATION r
<br /> .'.75-0.0-.'.1
<br /> DISCLOSURE OF LOBBYING ACTIVITIES PRCCUREUENT
<br /> Carl
<br /> Is this form applicaa to Your 5171-11?
<br /> YES El N:O'H',
<br /> If no,then please complete section 4
<br /> !below for"•Prime"
<br /> 1.Type of Federal Action: 2.Status of:Federa-Action: 3.Report Type:
<br /> a_contract a_bid/offerlapplication a_initial filing
<br /> b_grant b_initial award b_material change
<br /> c.cooperative agreement c.post-award For Matedal Change Only:
<br /> d_loan Year: Quarter
<br /> e.loan guarantee Date.of last report
<br /> f.loan;insurance (mmld'dlyyyy)
<br /> 4.Name and Address of Reporting Entity g_If Reporting;Entity in No_4 is a Subawardee,Enter Name and
<br /> ❑ Prime ❑ Subawardee Address of Prime:
<br /> Tier .ifknown.
<br /> Con ressionallDistrict,ifknomr4c Congressional!Ustrict,if knovin:
<br /> 6.Federal Department/Agency: 7.Federal Program Name/Description:
<br /> •CFDA;Number,if applicable:
<br /> 8.Federal Action lNumber,if known: 9.Award Amount,if known:
<br /> 10.a.Name andi Address of Lobbying Registrant lb.!Individuals:Performing Services(including address if
<br /> (if individual,last name,first name,.MI)c different from No. 1 Oa) I
<br /> (las€nate,Arstname,MJ):
<br /> l
<br /> i
<br /> j
<br /> 111. rnronnation requested through thiis form is authorized by tide 3'T
<br /> US_G_section$352.This disclosure of robbying..activities is a SlgnatUre_
<br /> maternal representation off-ad upon which raliancewas placed
<br /> by f.e Fier above when this fransacfi66 was made or entered -
<br /> into-ThEs'disclosure is required pursuant to 3.1 U.S.G.1352 Print Name: Y�--
<br /> This information will be auailabte for public rnspectian_Any
<br /> person who fallstofiretherequireddisclosureshaffbesubject T.itie.
<br /> to,a crMl penalty of n,ol less than 59[!,690 and notmare than
<br /> S-100MM!breach such failure. 'I ,
<br /> Telephone 110.:_ `1.1 a (mmldctl
<br /> Yy�`Y.)-
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<br /> 00474-2
<br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1123 43rd Ave Sidewalk Improvements 26th St.to Airport Dr
<br /> West\Admim\bid documents\Master Contract Documents\00474-CERTIFICATION for DISCLOSURE OF LOBBYING
<br /> ACTIVITIES.doc
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