NS EMS - Application for Emergency Performance Grant

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as • DISCLOSURE OF LOBBYING ACTIVITIES. Approved byoMe Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 03gg-0pgg fSee reverse fer rn~hlic hurrlnn dicni.,cu.n- • 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ~a. contract ~a. bidloffer/application ~a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. postaward For Material Change Only: d. loan year quarter e. loan guarantee date of last report f. loan insurance . Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee Enter Name Prime ~Subawardee , and Address of Prime: Tier , if known 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 $ 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (rf individual, last name, first name, MI): different ham No. 10a) (last name, first name, MI): 11. IMnrmation requested through this form is authorized by title 31 U.S.C. sectlon 1352. This disclosure of lobbying activities is a material Signature: representation of fact upon which reliance was placed by the tier above when this trensaction was made or entered into. This Print Name: disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be Tkle: available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less Telephone No.: Date: than $10,000 and not more than $100,000 for each such failure. Federal Use Only: Authorized for Local Reproduction Standard Fonn LLL (Rev. 7-97) C7