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00474 <br /> FATE oFFLORDA DEPARTMENT OFTRANSPMATION 3754130.34 <br /> PfMCUMEW <br /> DISCLOSURE OF LOBBYING ACTIVITIES MM6 <br /> Is this form applicable.t0yourfrin? <br /> YES 0 NO M <br /> If no,then please complete section 4 <br /> below for'Primer <br /> 1.Type of Federal Action: 2.Status of Federal Action: 3.Report Type: <br /> a.contract a.bidlofferlapplication a.initial firing <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.loanguarantee Date of last report <br /> L loan insurance (vnm/ddfyM) <br /> 4.Name and AddressofReporting Entity. S.If Reporting Entity in No.4 is a subawardee,Enter Name and <br /> Prime ❑ Subawardee 'Address of Prime: <br /> Tier— itknowtr E. <br /> Proctor Construction Com <br /> 2050 US Hwv 1.Ste 200 <br /> IF <br /> Vero Beach,EL,32260 <br /> Congtssional District iftnown:4c Cort gressionalDistrict,if know'n: is <br /> 7.Federal Program Name/DesuriDtion: <br /> 6.Federal Department/Agency: <br /> CFDA Number,if applicable. <br /> 8.Federal Action Number,if nown: 9i Award Amount,iftnown. <br /> 10.a.Name and.Address of Lobbying Registrant b.individuals Performing Services(including addrew if <br /> (ifindividual,last name,first name,Ml): diftrenf ftm No.10a) <br /> (last name,firstname,MO: <br /> 1.information requested through this form is authorized by Me 3'1 <br /> U.S.C.-sermon 1352.This disclosure of robbying-actlifilles Is a signature: <br /> inaterfar representation of fact upon which reliance was,pla"d <br /> by Bre tier above when this transaction was made,dr entered Print Wme: Donald L.Tolliver <br /> into.This disclosure Is required putsuantto 3vu.S.G.1352 <br /> This Infornwation will be available for public Inspection.Any <br /> person who falls to file the required disclosure shall he subject Title: Presodent/C00 <br /> to a CMI penalty at not less than$10,D00 and not mom than <br /> $100.000 for each such falture. Telephone No.:772.234.8164 Date(mmlddlyffl).' 1/19/17 <br /> A <br /> 1w,"- L1z-.;- <br /> M utharized for Local Reproduction <br /> Si:,, ard Form LLL(Rev.7-97) _J <br /> 00474-2 <br /> F-\PublicWoft\ENGINEERING DIVISION PROJECTS\1213C IRC Shooting Range HunterEduction Cla"roomki-Admin\Bld <br /> Documents\Master Contradt Do'curnents\00474-CERTIFICATION for DISCLOSURE OF LOBBYING ACTIVITIES.doc <br />