Assurances SF Lobby

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year _________ quarter _________
e. loan guarantee
date of last report ______________
f. loan insurance
4. Name and Address of Reporting Entity:
5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
Subawardee
and Address of Prime:
Prime
Tier ______, if known :

Congressional District, if known : 4c
6. Federal Department/Agency:

Congressional District, if known :
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 Registrant
( if individual, last name, first name, MI ):

b. Individuals Performing Services (including address if
different from No. 10a )
( last name, first name, MI ):

requested through this form is authorized by title 31 U.S.C. section
11. Information
1352. This disclosure of lobbying activities is a material representation of fact

Signature:

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 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.

Print Name:
Title:
Telephone No.: _______________________ Date:

Federal Use Only:

PRINT

Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

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 agreement to make
payment to any lobbying entity for influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employee of
Congress, or an employeeof a Member of Congress in connection with a covered Federal action. Complete all items that apply for both the initial filing and material
change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriateclassification
of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control
Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,
DC 20503.