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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 /> ❑ contract 0 bid/offer/application U. initial filing <br /> ❑ grant ❑ initial award ❑. material change <br /> Pcooperative agreement 0 post award <br /> loan For Material Change Only: <br /> loan guarantee year quarter <br /> fl 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 /> Ime bawardee Address of Prime: <br /> Per ,if known: <br /> Congressional District,if known: Congressional District,if known: <br /> Federal Department/Agency: Program Name/Description:enc : 7. Federal <br /> 6. p g y <br /> CFDA Number,if applicable: <br /> 8. Federal Action Number,if known: 9. Award Amount,if known: <br /> $ <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,Ml): <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 /> $ Zia! Dnned ❑a. retainer <br /> ❑b. one-time fee <br /> 12. Form of Payment(check all that apply): c. commission <br /> ❑ a. Cash ed. contingent fee <br /> Elb. In-kind;specify: —e. deferred <br /> p fY nature: —f. other;specify: <br /> value: — p ty' <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 H <br /> HCS-19-42-1801-198 <br /> City of Everett <br /> Page 2 of 4 <br />