Laserfiche WebLink
ATTACHMENT D <br /> Approved by OMB <br /> DISCLOSURE OF LOBBYING ACTIVITIES 0348-0046 <br /> Complete this form to disclose lobbying activities pursuant to 31 U .S. C. 1352 <br /> (See reverse for public burden disclosure .) <br /> 1. Type of Federal Action: 2 . Status of Federal Action : 3 . Report Type: <br /> Fa . contract F] a . bid/offer/application a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award <br /> d . loan For Material Change Only: <br /> e. loan guarantee <br /> f. loan insurance year quarter <br /> date of last report <br /> 4. Name and Address of Reporting Entity: 5 . If Reporting Entity in No. 4 is Subawardee, Enter Name <br /> and Address of Prime: <br /> � Prime � Subawardee <br /> Tier if known: <br /> Congressional District, if known: Congressional District, if known: <br /> 6. Federal Department/Agency: 7 . Federal Program Name/Description : <br /> CFDA Number, if applicable: <br /> 8. Federal Action Number, if known: 9 . Award Amount, if known: <br /> S <br /> 10 . a . Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br /> (if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name, MI): <br /> (attach Continuation Sheet(s) SF-LLL-A, if necessary) <br /> 11. Information requested through this form is authorized by title 31 U.S.C. Signature : <br /> section 1352. This disclosure of lobbying activities is a material <br /> representation of fact upon which reliance was placed by the tier above <br /> when this transaction was made or entered into. This disclosure is required Print Name : <br /> pursuant to 31 U.S.C. 1352. This information will be reported to Congress <br /> semi-annually and will be available for public inspection. Any person who <br /> fails to file the required disclosure shall be subject to a civil penalty of not Title: <br /> less than $ 10,000 and not more than $ 100,000 for each such failure. <br /> Telephone No . : Date: <br /> Federal Use Only: Authorized for Local Reproduction <br /> Standard Form - LLL ( Rev 7 - 97 ) <br /> DEP Contract No . RM026 , Attachment D. Page 1 of 2 <br />