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
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 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 :
Status of Federal Action a. Bid/Offer/Application b. Initial Award c. Postaward 3.
Status of Federal Action b. initial award c. post-award
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: □ A. Contract □ X. Xxxxx □ C. Cooperative Agreement □ D. Loan □ E. Loan Guarantee □ F. Loan Insurance
Status of Federal Action a. bid/offer/application b. initial award c. post‐award 3.
Status of Federal Action. 3. Report Type:
Status of Federal Action a. bid/ Proposal/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 Tier if known: Congressional District, if known: 5. If reporting entity in No. 4 is 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: $ 10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI): b. Individuals Performing Services(including address if different from No. 10a) (Last name, first name, MI): (attach Continuation Sheet(s) SF-LLL-A, if necessary) 11. Amount of Payment (check all that apply): $ actual planned 12. Form of Payment(Check all that apply): a. cash b. in-kind; specify: nature value 13. Type of Payment(check all that apply); a. retainer b. one-time fee c. commission d. contingent fee e. deferred f. other; specify 14. Brief Description of Service Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SF-LLL-A, if necessary) 15. Continuation Sheet(s) SF-LLL-A attached: Yes No 16. Information requested through this form is authorized by title 33 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 reported to Congress semi-annually and 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: Federal Use Only Authorized for Local Reproduction Standard Form - LLL This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or Contractor make payment to any lobbying entity for influencing or attempting to influence an officer or employee o...
