Standard Form-Lll - Disclosure Of Lobbying Activities - 1997
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1
2Disclosure of Lobbying Activities
Approved by OMB 0348-0046
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse side for Instructions and Public Reporting burden statement)
1. Type of Federal Action
2. Status of Federal Action
3. Report Type
contract
bid/offer/application
initial filing
a.
a.
a.
grant
initial award
material change
b.
b.
b.
cooperative agreement
post-award
c.
c.
For Material Change Only
loan
d.
year (yyyy) __________ quarter ___________
loan guarantee
e.
date of last report
loan insurance
(mm/dd/yyyy)_______________
f.
4. Name and Address of Reporting Entity
5. If Reporting Entity in No. 4 is Subawardee, enter Name and Address
Prime
Subawardee
Tier _________ , if known:
of Prime
Congressional District, 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
$
10a. Name and Address of Lobbying Registrant
b. Individuals Performing Services
(including address if different from No. 10a.)
(if individual, last name, first name, MI)
(last name, first name, MI)
(attach continuation sheet(s) if necessary)
11. Amount of Payment (check all that apply)
13. Type of Payment (check all that apply)
$ __________________
actual
planned
a. retainer
12. Form of Payment (check all that apply)
b. one-time fee
a. cash
c. commission
b. in-kind; specify: nature ______________________________
d. contingent fee
value _______________________________
e. deferred
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) if necessary)
15. Continuation sheets attached
Yes
No
16. Information requested through this form is authorized by Sec.319,
Signature
______________________________________________
Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104-
65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities
is a material representation of fact upon which reliance was placed
Print Name
______________________________________________
by the above when this transaction was made or entered into. This
disclosure is required pursuant to 31 U.S.C. 1352. This information
Title
______________________________________________
will be reported to the Congress semiannually and will be available
for public inspection.
Any person who fails to file the required
Telephone No. _____________________________________________
disclosure shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure.
Date (mm/dd/yyyy) __________________________________________
Authorized for Local Reproduction
Federal Use Only:
Standard Form-LLL (7/97)
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