Laserfiche WebLink
Is this form applicable to your firm? <br />YES ❑ NO <br />If no, then please complete section 4 <br />below for Trimer <br />1. Type of Federal Action: 2. Status of Federal Action: <br />3. Report Type: <br />a- contract a. bid/offerlappfcation <br />a. initial filing <br />b_ grant b- initial award <br />b_ material change <br />c_ cooperative agreement c. post -award <br />For Material Change Only: <br />d. loan <br />Year Quarter. <br />e- loan guarantee <br />Date of last report <br />f. loan insurance <br />(mmlddlyyyy) <br />4. Name and Address of Reporting Entity: <br />®'Prima ❑ Subawardee <br />5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and <br />Address of Prime: <br />Tier ifknown. <br />Conclressional District, ffknowm: <br />Z <br />Congressional District, ifknowm:4c <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Numbers ifappffcable: <br />8. Federal Action Number, if known: <br />9. Award Amount, if krxrwn: <br />S <br />10. a. Name and Address of Lobbying Registrant <br />b. individuals Performing Services (including address if <br />(if indnriduat last name, fort name, Mn: <br />Merent from No 10a) <br />(last name, first name, MO: <br />11.Ordormadon sequesred t=0 this fmrm is m dm rid by tide 31 <br />U.S.C. sec6on 1352 This disclosure of bbb*g ac&Mes-is a <br />maifet d repnesenfa6on of fact upon iwh%h aelance was placed <br />by 11ue bur above when this bansacdon was made or entered <br />irft. TMs Cmdosure is requited pursuant to 31 US.C. 135-1 <br />This infomea5on will! be available for puubfic inspection. Any. <br />person who bft to las the requored discbsure shau be subject <br />to a crhA penalty of not less than $10,0 and not moue dw. <br />mooAw br each such ralure. <br />Slgna4Ure: <br />'y <br />l� <br />Print Name- tb <br />Tule: �i 131r Y <br />-^� <br />Telephone No q / te (mm/dd/y)yy): 2— , 2 <br />Federal Use Onl y' <br />Authofaed for local Repeeuduc5on <br />Standard Form CLL(Rev. 7-07 <br />00474-2 <br />F:\PublicWorks\ENGINEERING DIVISION PROJECTS\1415-IR Blvd Sidewalk 37th St to 53rd St\1-Admin\bid documents\LAP <br />Documents\00474.- CERTIFICATION for DISCLOSURE OF LOBBYING ACTIVITIES.doc <br />