Request for Proposals Attachment 10 SF LLL Disclosure of Lobbying Activities Form

DISCLOSURE OF LOBBYING ACTIVITIES

OMB Number: 4040-0013
Expiration Date: 06/30/2028

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352

1. * Type of Federal Action:

2. * Status of Federal Action:

3. * Report Type:

a. contract

a. bid/offer/application

a. initial filing

b. grant

b. initial award

b. material change

c. cooperative agreement

c. post-award

d. loan
e. loan guarantee
f. loan insurance

4. Name and Address of Reporting Entity:
Prime

SubAwardee

* Name
* Street 1

Street 2

* City

State

Zip

Congressional District, if known:

5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime:

6. * Federal Department/Agency:

7. * Federal Program Name/Description:

Assistance Listing Number,
if applicable:

8. Federal Action Number, if known:

9. Award Amount, if known:

$

10. a. Name and Address of Lobbying Registrant:
Prefix

Middle Name

* First Name

* Last Name

Suffix

* Street 1

Street 2
State

* City

Zip

b. Individual Performing Services (including address if different from No. 10a) Prefix

Middle Name

* First Name

* Last Name

Suffix

* Street 1

Street 2

* City

11.

State

Zip

Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

* Signature:
*Name:

Prefix

* First Name

Middle Name

* Last Name

Title:

Federal Use Only:

Suffix

Telephone No.:

Date:
Authorized for Local Reproduction
Standard Form - LLL (Rev. 7-97)