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' SECTION 00644 - DISCLOSURE <br /> OF LOBBYING ACTIVITIES <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 /> ❑1 a. contract b. grant a. bid/offer/application a. initial filing <br /> c . cooperative agreement b. initial award b. material change <br /> d. loan c. post-award <br /> 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 /> 1 and Address of Prime: <br /> ❑ Prime ❑ Subawardee <br /> Tier if known: <br /> iCongressional District, if known: Congressional District, if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description : <br /> CFDA Number, if applicable: <br /> 1 8. Federal Action Number, if known: 9. Award Amount, ifknown: <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. l0a) <br /> (last name, first name. MI): <br /> attach Continuation Sheets SF-LLL-A, if necessary) <br /> I11 . Information requested through this form is authorized by title 31 U.S.C. Signature:section 1352. This disclosure of <br /> lobbying activities is a material <br /> representation of fact upon which reliance was placed by the tier above Print Name: <br /> when this transaction was made or entered into. This disclosure is required <br /> pursuant to 31 U.S.C. 1352. This information will be reported to Congress Title: <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 Telephone No.: Date: <br /> less than $10,000 and not more than $100,000 for each such failure. <br /> Federal Use Only: Authorized for Local Reproduction <br /> ' Standard Form — LLL (Rev 7 — 97) <br /> 00644- 1 <br /> 00644 — Disclosure of Lobbying Activities <br /> F:\Public Works\KeithM\Stormwater Projects\Gifford East\Construction Contract\Bidding & Contract Documents\Bidding & Contract <br /> 1 Documents\00644 - Disclosure of Lobbying Activities.doc <br />