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35 <br /> DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-4045 <br /> (See reverse for public burden disclosure.) <br /> 1.Type of Federal Action: `2. Status of Federal Action: 3. Report Type: <br /> a. contract [ I a. bid/offer/application ` a. initial filing <br /> b. grant b. initial award ' b. material change <br /> c. cooperative agreement c. post-award For Material Change Only: <br /> d. loan year quarter <br /> e. loan guarantee date of last report <br /> f. loan insurance <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br /> El Prime ❑Subawardee and Address of Prime: <br /> Tier if known: <br /> ORANGE COUNTY <br /> 200 SOUTH CAMERON STREET <br /> HILLSBOROUGH,NC 27278 <br /> Congressional District,if known: 0 Congressional District,if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> RBCS BUSINESS ENTERPRISE GRANTS <br /> CFDA Number, if applicable: 10.3 51 <br /> 8. Federal Action Number,if known: 9.Award Amount, if known: <br /> 10.a. Name and Address of Lobbying Entity b.Individuals Performing Services (including address if <br /> (if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name, Ml): <br /> 11.Amount of Payment(check all that apply): 13.Type of Payment(check ail that apply): <br /> ❑actual ❑planned ❑a.retainer <br /> ❑b.one-time fee <br /> 12. Form of Payment(check all that apply): ❑c.commission <br /> El a.cash ❑d.contingent fee <br /> ❑b.in-kind;specify:nature ❑e.deferred <br /> value ❑f.other;specify: <br /> 14,Brief Description of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s),or <br /> Member(s)contacted,for Payment Indicated in Item 11: <br /> RBCS ENTERPRISE GRANTS <br /> (attach Continuation Sheet(s)SP-LLLA,if necessary) <br /> 15.Continuation Sheet(s)SF-LLLA attached: ❑Yes ❑No <br /> 16-l]n 3o Tabhias n d resqessutere d o hf lroobugyh i hng is a ctifom,eis s a ta h omrazted ri abl y r ehpEfe re Sse n]U ta tiS o Cn.osf cocon <br /> i upon Signature: <br /> Which reliance was placed by the filer above when this transaction was made or <br /> entered into.This disclosure is required pursuant to 31 U.S C.1352 This Print Name: <br /> infoumabun will be reported to the Congress semi-annually and wilt be available for <br /> public inspection.Any person who faits to Me the required disclosure shall be sub ect Title: <br /> to a dvi]penalty of not less that 510.000 and not more than 5100.000 for each such <br /> failure- Telephone No.: Date: <br /> : zLy Authorized for Local Reproduction <br /> ° x � I ��� c �_ Standard Farm LLL(Rev.7-97) <br />