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 byO"° <br /> os.e-ao.e <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 <br /> (See reverse for public burden disclosure.) <br /> I. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> a.contract CI a. bid/offer/application raia.initial filing <br /> b.grant b.initial award b.material change <br /> c.cooperative agreement c.post-award For Material Ctsange Only: <br /> d.loan <br /> e.loan Fuarantee year quarter <br /> f. loan insurance date of last report <br /> 4. Name and Address of Reporting Entity: S. II Reporting Entity in No.4 is Subawardee,Enter Name <br /> 0 Prime 0 Subawardee and Address d Prim.. <br /> Tier ,if known: <br /> Congressional District,if known: Congressional District,if known: <br /> 0. Federal Department/Agency: T. Federal Program Name/Descriptiort <br /> CFDA Number,if applicable: <br /> 5. Federal Action Number,if known: 9. Award Amount,if known: <br /> 10. a.Name and Address d Lobbying Entity b.Individuals Performing Services(including address if <br /> (if individual,last name,first name,MU: different from No,10aT <br /> (last name,first name,Mn: <br /> (mach Connnuarion She.l(s)SN.u•,,ifnecessan0 <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> 5 0 actual 0 planned 0 a.retainer <br /> ❑ b.one-time fee <br /> 12. Form of Payment(check all that apply): 0 c.commission <br /> 0 a.cash 0 d.contingent fee <br /> ❑ b.in-kind;specify nature ❑ e.deferred <br /> ry' ❑ f. other;specify:pe iy: <br /> value <br /> 14. Reef Description d Services Performed or to be Performed and Date(s)of Service,including offcersl,employees), <br /> or Memberts)contacted,for Payment Indicated in Item 11: <br /> (anscb communion Moar(s)SF-tit-A tl ne(edsanl <br /> 15. Continuation Sheet(s)SFLLLA attached: 0 Yes ❑No <br /> 16. Nareb000n r.wesnd anon',the keno n s.nw.d M One lr U.SC el� <br /> racoon 1111.ibis 1 d saw,.y tcrMas a a moot,,wmm odoo Sig ufe' <br /> ar bct open M..raa.c..r plm.d by 1M twr Lb... skis <br /> toieuucteon vow,.es.«.,.o.oa mu.ebb a....w.my.*p.n...nt to Print Nam. <br /> Sr U.S.C.liSl Thrt.,b..swon boll be,euerbd to e..C.e500 r.yw <br /> wwray end will be nJ.ble in public obtoceon Sn,p.on.I..Wt m Tefe: <br /> lie she.s.,ired d Wow.*that by tubiact i e owl Mn.itr al not Iris eun <br /> Swan and so was than stmaa0 so,ach sow taaw. Telephone No.: Date: <br /> iNf '?' •€ n €A* wIts bust ariverivolva <br /> sana+.e ran,.-w <br /> 262 <br />