|
<br />D'JdOSURE OF LOBBYING AGh.fIES
<br />
<br />APpfCWrO by OMB
<br />OJ~
<br />
<br />Complete this form to disclose lobbying acth;iti~s pursuant to 31
<br />(See reverse for public burden disclosure.)
<br />
<br />use. 1352
<br />
<br />1. Type or F~tnl Action:
<br />
<br />D a. contract
<br />b. &rant
<br />c. cooper,ltivf: "I,ee-me-nt
<br />d. loan
<br />t. loan luarantee
<br />f. loan insurance
<br />
<br />2. St.otu. 01 Fed...ol Action:
<br />
<br />D ... bid/offer/application
<br />b. Initial award
<br />c. post-award
<br />
<br />3. aeport Typo:
<br />
<br />D.. initial filina
<br />b. material chanle
<br />
<br />For Matori.1 Ch.n.e Only:
<br />year quarter
<br />d.te of I..t ,eport
<br />
<br />S. If aeportlnl Entity in No.4 I. Subaw.rd~, Ent...
<br />N.... .nd Addross of Pri...:
<br />
<br />4. N.me .nd Add,e.. of aeportin. Entity:
<br />
<br />o Prime
<br />
<br />o Subawardee
<br />
<br />Tier _. if known:
<br />
<br />Consreniona,1 District, if known:
<br />6. Feder.1 Dep.rtment/Alencr:
<br />
<br />COn&~nll District, il known:
<br />7. Foder.ll'roIr.m N.moIDHcription:
<br />
<br />10. .. N.me .nd Add.... of Lobbyinl Entity
<br />(if individual, Ian name, firs! n.ame, MI):
<br />
<br />(FDA Number. if .pplicable:
<br />9. Aw.rd Amount, ff known:
<br />S
<br />b. Indlvidu.l. "erlonnlna Services
<br />(including address if different (rom No. lOa)
<br />(last name, first name, MI):
<br />
<br />8. Feder,,1 Action Number, if 1-nown:
<br />
<br />r,UlKh COtuinu"iOft ~fJl SF.LLt...... jf nK~U'Y'
<br />
<br />s
<br />
<br />o actual
<br />
<br />o plannod
<br />
<br />13. Typo of Paymonl (check .11 th.t .pply):
<br />
<br />o I. retainer
<br />o b. one-time fee
<br />o c. commission
<br />o d. continaent fee
<br />o e. deferred
<br />o f. other; specify:
<br />
<br />11. Amount of "ayment (check .11 th.t .pply):
<br />
<br />12. Form of ".yment (check .11 th.t apply):
<br />o I. cash
<br />o b. in.kind; speCify: nature
<br />
<br />value
<br />
<br />t4. Brief Description of Services "erlormed or 10 be "erlonned .nd O.te(.) of Service, indudin. officerl.),
<br />employ~l.), or Membe"l.) cont.cted, for ...ym.nt Indic.tod in item 11:
<br />
<br />(.auKh CCIo"II;"II.aIOorl S/'lf'f'lfl} Sf.lLt.A. i/lW'('ftI,.lIryJ
<br />
<br />IS. Contlnu.tion Sh~I(.) SF.LLL.A .ttached:
<br />
<br />DYe.
<br />
<br />o No
<br />
<br />16. l"fQfI'l'l.atoOl'l rtoq"'HIt'dlh'Oo.Ilh Ihlllo'''' n.uthorizt'd bytit!t l1 use.
<br />N'<liOl" 1352 Thit dit.clclIIuP'I' of Ic>bbyi". ...eli"ititt is... 1'1'I.1,,"...1 r~
<br />1'1001'1 of bel IIpoi'! ....hiCh rtli,I'IU "'.11I pl.act'd by 1M tOtf ,boy, whrI'I
<br />thil u.anuelton _,. m,dt Of ."ttft'd '1'110. Thil cl'ICIOtllf. iIIPQ",ift'd
<br />P\lfll.la"l to )1 U 5 C. 1352 Th'l ",ronn...lton will bot ft'PO"td to the
<br />Conlft'lI u-mi",.,.""lly anclwm bot' ,,,,d,ble for pub4ic inlpt'(lioft Afty
<br />pe-f~ who billlo tilt the ft'Quift'd di~lon"f ltall brt Il.Ib;t-clto. civil
<br />pt'n.l1y of Mtl I,u Ih.n no,ooo .ncl nol mOlt Ih.an $100,000 tor tleh
<br />I...chbil""t.
<br />
<br />Slln.ture:
<br />Print N.me:
<br />Title:
<br />r e1ephone No.'
<br />
<br />O..te:
<br />
<br />Z~ ~ ~ '/ ,,- v -i" ,
<br />"";:~:"~i~~'ij~~~:'; ,:;;{"'::~,?V ':;~ ':., , ~ ", ' , .
<br />~-x~","'J:..~ :'>>~'~M' iU,' ,,V, ,
<br />-' ,,,' --~-~~- - .., .,
<br />
<br />Authoriuod'Of Loullt'prod...ctiol'l
<br />Sul'ld"cl FomI . UL
<br />
|