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Federal Register Vol.54.No.243/Wednesday,December 20,1989/Notices 52323 <br /> 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 /> ❑ a. contract El a. bid/offer/application ❑ a. initial filing <br /> El b. grant El b. initial award ❑ b. material change <br /> 8 c. cooperative agreement El c. post award <br /> ❑ d. loan For Material Change Only: <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 and <br /> Prime Subawardee Address of Prime: <br /> Tier ,if known: <br /> Congressional District, if known: Congressional District,if known: <br /> 6. Federal Department/Agency: 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, MI): <br /> (attach Continuation 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 /> $ ❑ actual ❑ planned ❑ a. retainer <br /> ❑ b. one-time fee <br /> 12. Form of Payment(check all that apply): c. commission <br /> ❑ a. Cash d. contingent fee <br /> 1:1b. In-kind;specify: nature: = e. deferred <br /> p f. other;specify: <br /> value: — <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s),or <br /> member(s)contacted,for payment indicated in item 11: <br /> (attach Continuation Sheet(s)SF-LLL-A if necessary) <br /> 15. Continuation Sheet(s)SF-LLL-A attached: ❑ Yes ❑ No <br /> 16. Information requested through this form is authorized by title 31 <br /> U.S.C.section 1352. This disclosure of lobbying activities is a Signature: <br /> material representation of fact upon which reliance was placed <br /> by the tier above when the transaction was made or entered Print Name: <br /> into. This disclosure is required pursuant to 31 U.S.C. 1352. <br /> This information will be reported to the Congress semi-annually Title: <br /> and will be available for public inspection. Any person who <br /> fails to file the required disclosure shall be subject to a civil Telephone No.: Date: <br /> penalty of not less than$10,000 and not more than$100,000 <br /> for each such failure. <br /> Federal Use Only. Authorized for Local production <br /> Standard Form—LLL <br /> Exhibit J <br /> HCS-16-42-1601-198 <br /> City of Everett <br /> Page 2 of 4 <br />