Laserfiche WebLink
Pt. 21, App. B 31 CFR Subtitle A (7-1-06 Edition) <br /> APPENDIX B TO PART 21—DISCLOSURE FORM TO REPORT LOBBYING <br /> DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> 03a&OOd6 <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 /> a.contract Ti a. bid/offer/application a.initial filing <br /> b.grant I—Ib.initial award LI b.material change <br /> c.cooperative agreement For Material Change Only: <br /> d.loan c. post-award B <br /> e.loan guarantee year quarter <br /> f. loan insurance date of last report <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee.Enter Name <br /> 0 Prime ❑ and Address of Prime: <br /> Subawardee <br /> Tier ,if known: <br /> Congressional District,if known: Congressional District,if known: <br /> 6. Federal DeparlmenVAgency: 7. Federal Program Name/Description: <br /> CFDA Number,if applicable: <br /> 8. Federal Action Number,if known: 9. Award Amount,if known: <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,MD: <br /> (attach Conlmvation Sheet(s)Sf-lll-A if necessary) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> $ 0 actual 0 planned 0 a. retainer <br /> 0 b.one-time fee <br /> 12. Form of Payment(check all that apply): ❑ c. commission <br /> ❑ a. cash 0 d.contingent fee <br /> ❑ b.in-kind;specify: nature ❑ e.deferred <br /> P ry' - ❑ f. other;specify: <br /> P N- <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Dates)of Service,including officer(sl,employee(s), <br /> or Member(s)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation Sheet(s)SF-LLl-A if necessary) <br /> 15. Continuation Sheets)SF-ILL-A attached: 0 Yes 0 No <br /> 16. innnnata,e requested through this bum is auth«ised by tide 3+u.s.C. <br /> tion nu.Thik diacbsun d bbbyini ac<min is a material,epakentation Signature: <br /> d fact upon,.bite nippy.was placed be Ine tier above when this <br /> 1er..mr dodos,...h requeed pun..,to Print Name: <br /> s1 USeC.1131.this information.in be reported to the Congress semi. <br /> .'orgy and en.be available In,public,npection.Any person who lark to Title: <br /> Me the required diacbwre shall S.wbsect to a call penalty of not Ins than <br /> s+o,0 fled,rot en,.than t1...o..r«.acn keen eiwr.. Telephone No.: Date: <br /> FiniellitOs*Orir Authorised tor local Reproduction <br /> sla.laara Fwm-ul <br /> 262 <br />