Laserfiche WebLink
<br />COPS in Schools Application Forms <br /> <br />Disclosure of Lobbying Activities <br /> <br />Approved by OMB <br />0348-0046 <br /> <br />(as amended) <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for instructions and public burden disclosure) <br /> <br />1. Type of Federal Action: _ <br />a. contract <br />b. grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br /> <br />2. Status of Federal Action: <br />a. bid/offer/application <br />b. initial award <br />c. post-award <br /> <br />3. Report Type: _ <br />a. initial filing <br />b. material change <br /> <br />For Material Change Only: <br />Year: <br />Quarter: <br />Date of last report <br /> <br />4. Name and Address of Reporting Entity: <br />o Prime 0 Subawardee <br />Tier ~ if known: <br /> <br />5. If Reporting Entity in No.4 is Subawardee, Enter <br />Name and Address of Prime: <br /> <br />Congressional District (number), ifknown:_ <br /> <br />Congressional District (number), ifknown:_ <br /> <br />6. 'Federal Department/Agency: <br /> <br />7. Federal Program Name/Description: <br /> <br />CFDA Number, if applicable: <br /> <br />8. Federal Action Number, if known: <br /> <br />9. Award Amount, if known: <br /> <br />$ <br /> <br />10. a. Name and Address of Lobbying Registrant <br />(if individual, last name, first name, MI): <br /> <br /> <br />10. b. Individuals Performing Services <br />(including address if different from No. lOa) <br />(last name, first name, MI): <br /> <br />11. Information requested through this form Is authorized by Title <br />31 U.s.C. Section 1352. This disclosure oflobbying activities Is a <br />material representation of fact upon which reliance was placed by <br />the tier above when this transaction was made or entered Into. <br />This disclosure Is required punuant to 31 U.S.C. 1352. This <br />Information will be reported to the Congress semi-annually and <br />will be available for public inspection. Any person who fails to file <br />the 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. <br /> <br />Print Name: <br /> <br />Title: Interim City Manager <br /> <br />Telephone No.:(903) 784-9201 <br /> <br />Date: 5-17-04 <br /> <br />Federal Use Only: <br /> <br />Authorized for Local Reproduction, Standard Form - LLL <br /> <br />Updated: February 14, 2002 <br />e02021440 <br /> <br />18 <br />