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FF.CCU4E4t3!IC C n r as F�5e s c'. INSTRUCTIONS FOR COMPLETION OF SF -LLL DISCLOSURE OF LOBBYING ACTIVITIES This disclosure ferns shall be completed by titre reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. Tse filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Complete al, items that apply for bath the initial filing and matenai change report. Refer to the imptementing guidance published by the Office of Management and Budget for additional information. i. Identify the 'type of covered Federal action for which lobbying activity is andlor has been secured to infuence the outcome of a covered Federal action. 2. Iderlffy the status of the covered Federal action. 3. Identity the appropriate classification of this report. If this is a foilowup report caused by a crated 11 change to the information previously reported, enter the year and quarter in which the change occurred. Enter the date of Me lost previously submitted report by this reporting entity for this covered Federal action. 4. Enter the fuilname, address, city. State and zip code of the reporting entity. Include Congressional Dist ct, if known. Check the appropriate classification of the reporting entity that designates it it is_ or expects to be, a prise or subaward recipient. Identify the tier of the sui)awardee. e.g., the first subawardee of the prime is the 1 st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants. 5. If the organization filing the report in item 4 checks "Subawardee." then enter the fill name, address. city. State and zip code of the prime Federal recipient. Include Congressional District, if known. 5. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For example- Department of Transportation, United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action ;item 1. If known. enter the full Catalog of Federal Domestic ,Assistance (CFDA) number for grants, cooperative agreements. loans. and loan commitments. S. Enter the most appropriate Federal identifying number available for the Federal action identified in item, 1 (e.g., Request for Proposal (,RFP) number; Invitation for Bid (IFBI number, grant announcement number; the contract. grant, or loan award number; the app€icatiorliproposal control number assigned by the Federal agency). !nclude prefixes. e.g., "RFP -DE -90-001." 9. For a covered Federal action where there has been an award or loan commitment by tr:e Federai agency, enter the Federal amount of the award loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the Pill name, address, city. State and zip code of the Lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity identified in item 4 to influence the covered Federal action. fb} Enter the full names of the individuai(s) performing services, and include Pill address if different from 10 (a . Enter Last Name. First Name, and Middle Initial (MI), 11. The certifying official shall sign and date the form, print his/her name, title, and telephone number. Aocording to he Paperwork Reduction Act, as arnerded, no persons are required to respond to a collecton of information unless it displays a valid CRAB Ccrtrcl Number. Thp- valid ONIS oontrol number for this informadon collector. is 01MB No. 034E-0046. Public ;eporim3 burden for this collection of infcrmatcn is estimated to average 20 minutes oer response, incuding time for reviewing ins-trunztons, searching existing data 'sour-oes, gatheeng and maintaining he data needed, and completing and revietirng he collection of irtormation_ Send comments regarding the burden estimate or any other aspect of this collection, of informatkin, im-luding suggestons rcr redudng this burden,, to he Cffoe of Managemem and Budges Paperwork P.educticn Project (.0345 -MY -6). V.'ash.':ngton. DC 2066.03. 00474-3 F:\Public Works\ENGINEERING DIVISION PROJECTS\1503-43rd Ave Swk Airport Dr to 41st St\1-Admin\Bids\Bid Documents\LAP Documents\00474 - CERTIFICATION for DISCLOSUR-E OF LOBBYING ACTIVITIES.doc