2015-120 EMS -NC Emergency Management - 2015 EMPG Application Checklist for Local EM Program

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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 0348-0046 1.*Type of Federal Action: 2.*Status of Federal Action: 3.*Report Type: FRIa.contract a.bid/offer/application a.initial filing b.grant b.initial award x �b.material change n c.cooperative agreement El c.post-award ❑d.loan e.loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: Prime 1-1SubAwardee *Name `Street 1 Street 2 S. CaMt..��a City State ,1 C Zip Congressional District,if known: 'V 5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime: 6.*Federal Department/Agency: 7.*Federal Program Name/Description: 7 CFDA Number,ifapplicable: 8.Federal Action Number,if known: 9.Award Amount,'if known: 10.a.Name and Address of Lobbying Registrant: �Q Prefix 'First Name Middle Name 'Last Name Suffix E *Street 1 Street 2 ` city State Zip b. Individual Performing Services(including address if different from No.10a) AO Prefix ��l*First Name Middle Name I1 'Last Name Suffix E *Street 1 Street 2 `City State Zip 11, information requested through this form is ized by title 31 U.S.C.section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above n transaction was made 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 wit a av ' ble 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 foi ch such failure. *Signature: *Name: refs `First Name Middle Name `Last Name suffix Title: Telephone No.: Date: L__44iL1A4S _J AU41norized for Local Reproduction Standard Form-LLL(Rev.7-97)