Form Sf-Lll - Disclosure Of Lobbying Activities printable pdf download

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

and Address of Prime:

Prime

Subawardee

Tier ______, if known :

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

b. Individuals Performing Services ( including address if

( if individual, last name, first name, MI ):

different from No. 10a )

( last name, first name, MI ):

(attach Continuation Sheet(s) SF-LLLA, if necessary)

11. Amount of Payment ( check all that apply ):

13. Type of Payment ( check all that apply ):

$ ___________

planned

a. retainer

actual

b. one-time fee

12. Form of Payment ( check all that apply ):

c. commission

a. cash

d. contingent fee

nature __________

b. in-kind; specify:

e. deferred

value __________

f. other; specify: _________________________

14. Brief Description of Services 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-LLLA, if necessary)

15. Continuation Sheet(s) SF-LLLA attached:

Yes

Information requested through this form is authorized by title 31 U.S.C. section

16.

Signature:

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

Print Name:

or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This

information will be reported to the Congress semi-annually and will be available for

Title:

public inspection. Any person who fails to file the required disclosure shall be

subject to a civil penalty of not less that $10,000 and not more than $100,000 for

Telephone No.: _______________________ Date:

each such failure.

Authorized for Local Reproduction

Federal Use Only:

Standard Form LLL (Rev. 7-97)

Form Sf-Lll - Disclosure Of Lobbying Activities

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