Snohomish County Human Services 10/6/2022

Exhibit D BH-22-AR-04-198 City of Everett Page 2 of 4 DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB 1352 0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. (See reverse for public burden disclosure.) 1. Type of Federal Action: a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance 2. Status of Federal Action: a. bid/offer/application b. initial award c. post-award 3. Report Type: a. initial filing b. material change For Material Change Only: year quarter . date of last report 4. Name and Address of Reporting Entity: Prime Subawardee: Subawardee Tier , if known : Congressional District , if known :4c 5. If Reporting Entity in No. 4 is a Subawardee: Enter Name and Address of Prime: Congressional District, if known : 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable : 8. Federal Action Number, if known : 9. Award Amount, if known : $ 10a. Name and Address of Lobbying Entity (if individual, last name, first name, MI ): (attach Continuation Sheet(s) SF-LLLA, if necessary) b. Individuals Performing Services (including address if different from No. 10a ) (last name, first name, MI ): 11. 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 this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information 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: Print Name: Title: Telephone No.: Date: Continuation Sheet(s) SF-LLLA attached : Yes No Federal Use Only: