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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br /> (See reverse for public burden disclosure.) <br /> 1.Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> 11.3 a. contract q �a. bid/offer/application A a. initial filing <br /> LL�-JJ b. grant - �b. initial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Only: <br /> d. loan year quarter <br /> e. loan guarantee date of last report <br /> f. loan insurance <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br /> Q Prime El Subawardee and Address of Prime: <br /> Tier , if known: <br /> City of Everett <br /> 2930 Wetmore Ave <br /> Everett,WA 98201-4067 <br /> Congressional District, if known: Congressional District, if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> U.S.DOJ <br /> Officer of Justice Programs <br /> CFDA Number, if applicable: <br /> 8. Federal Action Number, if known: 9.Award Amount, if known: <br /> $ <br /> 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if <br /> (if individual. last name. first name. MI): different from No. 10a) <br /> N/A (last name. first name. MI): <br /> N/A <br /> 11.Information requested through this form is authorized by title 31 U.S.C.section Signature: _ -1352. This disclosure of lobbying activities is a material representation of fact ,"1�-/2n <br /> upon which reliance was placed by the tier above when this transaction was made Print Name: C!S�(J/(,_ -r . it--1-t <br /> N) <br /> or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This <br /> information will be reported to the Congress semi-annually and will be available for <br /> public inspection. Any person who fails to file the required disclosure shall be Title: Mayor �xy �`7 <br /> subject to a civil penalty of not less that$10,000 and not more than$100,000 for (425)257-7112 t.] r/ ^�j <br /> each such failure. Telephone No.: Date: <br /> Federal Use Only: Authorized for Local Reproduction <br /> Standard Form LLL(Rev.7-97) <br /> Office of the City Attorney A 5 , <br /> APPROVED AS TO FORM <br /> David C.Hall,City Attorney <br /> Cit Clerk <br />