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<br /> P'pc 2 W2
<br /> INSTRUCTIONS FOR COMPLETION OF SF-LLL,DISCLOSURE OF LOBBYING ACTIVITIES
<br /> This disclosure farm shall be completed by the reporting entity,whether subawardee or prime Federal recipient,atthe
<br /> initiation or receipt of a covered Federal action,or a material change to a previous filing,pursuant to title 31 U`_S_G.
<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 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 Referto 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 and/or has been secured to infiuen ce 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 zipp code of the reporting entity_Include Congressional District, if
<br /> known_Check the appropriate classification of the reporting entitythat 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 notlimitedto subcontracts,subgrants and contractawards undergrants.
<br /> 5- if the organization filing.the.report in item 4 checks"Subawardee,"then enter the full name,address,city,State
<br /> and zip code of the prime Federal recipient.Include Congressional District,if known.
<br /> 6- Enter the.name of the Federal agency making the:award or loan commitment include at least one organizational
<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 j
<br /> commitments. i
<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(1F8)number,grant announcement number the contract.;
<br /> grant,or roan award number-,the applicationtproposal control number assigned bythe Federal agency)-include
<br /> prefixes,e_g_,"RFP-DE-90-001.'
<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 of the awardlloan commitment for the prime entity id'entifred in item 4 or 5.
<br /> i
<br /> 10.
<br /> (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 ofthe individual(s)performing services,and include full address if differentfrom 10(a)-
<br /> Enter Last Name,First Name,and Middle Initial(MI).
<br /> 11-The certifying.official shall sign and date the form,print hisdher name,title,and telephone number_
<br /> Acoonimg id the Paperwork Reduction Act.as amended.mpersans are required to resixind la.amifec5on of irrronnalron unlEss.R displays a
<br /> valid OM6 Contror l lumber The valid ONG control numberfortHs in.`orma5an colCedion is OA4B No.6348#746.Public reporting burdenforthis
<br /> colfection of infarmafion is estirnated to averaga 16 minutes per response,rndudng time for reviewing insbuc&m,searching wasEirig data sources,
<br /> gathering and marntatning lhedata needed.and completing and reuie ring fhe eolrecEan ofinfonnaffan.Send com,rents regarding the burden
<br /> esiicnatearanyotheraspectd'fthis.coitecticn ofinrarrrrarran,ir.wAudng suggestiarrsfbrreducing this burden,iD the Office of hlanagernent and
<br /> Budget,Paperwork Reduction Project(6346{]M} ,Washington.DC 26-63.
<br /> 00474-3
<br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1123 43rd Ave Sidewalk Improvements 26th St.to Airport Dr
<br /> West\Admim\bid documents\Master Contract Do8uments\00474-CERTIFICATION for DISCLOSURE OF LOBBYING
<br /> ACTIVITIES.doc
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