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l <br /> Federal R-.inter Vol.54.No.243!Wednesd. ,December 20,19891 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 a. bid/offer/application a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement 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 <br /> Prime SubawardeeName and 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 /> (f 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): D c. commission <br /> ❑ a. Cash ❑ d. contingent fee <br /> b. In-kind;specify: nature: ❑ e. deferred <br /> value: ❑ f. other;specify: <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 0 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 by <br /> the tier above when the transaction was made or entered into. Print Name: <br /> This disclosure is required pursuant to 31 U.S.C.1352. This <br /> information will be reported to the Congress semi-annually and will <br /> be available for public inspection. Any person who fails to file the Title. <br /> required disclosure shall be subject to a civil penalty of not less <br /> than$10,000 and not more than$100,000 for each such failure. Telephone No.: Date: <br /> Federal Use Only: Authorized for Local production <br /> Standard Form-ILL <br /> Page 2 of 4 10/3/2003 p:kity of everett home 2003#21atlachment g-lobbying-doc'sma <br />