Laserfiche WebLink
Approved by OMB <br />Disclosure of Lobbying Activities <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for Dublic burden disclosure) <br />0348-0046 <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />a. contract <br />a. bid/offer/application <br />a. initial filing <br />X b. grant <br />x b. initial award <br />b. material change <br />c. cooperative agreement <br />c. post -award <br />d. loan <br />For material change only: <br />e. loan guarantee <br />Year quarter <br />f. loan insurance <br />Date of last report <br />4. Name and Address of Reporting Entity: <br />5. if Reporting Entity in No. 4 is Subawardee, Enter <br />Prime X Subawardee <br />Name and Address of Prime: <br />Tier , if Known: <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />Dept of the Treasury <br />CFDA Number, if applicable: N/A <br />8. Federal Action Number, if known: <br />9. Award Amount, if known: <br />10. a. Name and Address of Lobbying Registrant <br />b. Individuals Performing Services (including address if <br />(f individual, last name, first name, MI): <br />different from No. IOa) <br />N/A <br />(last name, first name, MI): <br />N/A <br />11. Information requested through this form is <br />J4— <br />authorized by title 31 U.S.C. section 1352. This <br />Signature: <br />disclosure of lobbying activities is a material <br />representation of fact upon which reliance was placed <br />Print Name: miannePFlae <br />by the tier above when this transaction was made or <br />entered into. This disclosure is required pursuant to 31 <br />Title: President <br />U.S.C. 1352. This information will be reported to the <br />Congress semi-annually and will be available for public <br />Telephone No.: 772-567-7790 Date: 06/14/2022 <br />inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less <br />than $10,000 and not more than $100,000 for each such <br />failure. <br />Federal Use Only <br />Authorized for Local Reproduction <br />Standard Form - LLL (Rev. 7-97) <br />