Exhibit 10-Q - Disclosure Of Lobbying Activities Form

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Local Assistance Procedures Manual
EXHBIT 10-Q
Disclosure of Lobbying Activities
E
10-Q D
L
A
XHIBIT
ISCLOSURE OF
OBBYING
CTIVITIES
COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. initial
a. bid/offer/application
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
d. loan
For Material Change Only:
e. loan guarantee
year ____ quarter _________
f. loan insurance
date of last report __________
4.
Name and Address of Reporting Entity
5. If Reporting Entity in No. 4 is Subawardee,
Enter Name and Address of Prime:
Prime
Subawardee
Tier _______ , if known
Congressional District, if known
Congressional District, if known
6.
Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number, if applicable ____________________
Federal Action Number, if known:
9. Award Amount, if known:
8.
10.
Name and Address of Lobby Entity
11. Individuals Performing Services
including address if different from No. 10a
(If individual, last name, first name, MI)
(If individual, last name, first name, MI)
(attach Continuation Sheet(s) if necessary)
12.
Amount of Payment (check all that apply)
14.
Type of Payment (check all that apply)
$ _____________
actual
planned
a. retainer
b. one-time fee
13.
Form of Payment (check all that apply):
c. commission
a. cash
d. contingent fee
b. in-kind; specify: nature _______________
e deferred
Value _____________
f. other, specify _________________________
15.
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:
16.
Continuation Sheet(s) attached:
Yes
No
(attach Continuation Sheet(s) if necessary)
Information requested through this form is authorized by Title
17.
31 U.S.C. Section 1352. This disclosure of lobbying reliance
Signature: ________________________________________
was placed by the tier above when his transaction was made or
entered into. This disclosure is required pursuant to 31 U.S.C.
Print Name: _______________________________________
1352. This information will be reported to Congress
semiannually and will be available for public inspection. Any
Title: ____________________________________________
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
Telephone No.: ____________________ Date: ___________
$100,000 for each such failure.
Authorized for Local Reproduction
Federal Use Only
Standard Form - LLL
:
Standard Form LLL Rev. 04-28-06
Distribution: Orig- Local Agency Project Files
Page 1
LPP 13-01
May 8, 2013

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