WA State Military Department FEMA Grant 10/4/2016

DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 (See reverse for public burden disclosure) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: na.contract a.bid/offer/application a. initial filing b.grant b.initial award b. material change c.cooperative agreement c. post-award For Material Change Only: d. loan year quarter e. loan guarantee date of last report f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee, Enter Name nPrime nSubawardee and Address of Prime: Tier ,if known: Congressional District,if known: 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: 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services(including address if (if individual, last name, first name, MI): different from No. 10a) (last name, first name, Ml): 11. Information requested through this form is authorized by title 31 U.S.C.section 1352. This disclosure of lobbying activities is a material Signature: representation of fact upon which reliance was placed by the tier / above when this transaction was made or entered into. This Print Name: / Spw/er.r.""✓ disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be Title: /v` ay a de available for public inspection. Any person who fails to file the �/ 1+11k required disclosure shall be subject to a civil penalty of not less Telephone No.: Date. than$10,000 and not more than$100,000 for each such failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL(Rev.7-97)