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37 <br /> DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br /> (See reverse for public burden disclosure.) <br /> 1.Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> a. contract 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 /> 1 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: 10.3s 1 <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 all that apply): <br /> $ Ei actual ❑planned E a. retainer <br /> ❑b.one-time fee <br /> 12. Form of Payment(check all that apply): ❑c.commission <br /> ❑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)SF-LLIA,if necessary) <br /> 15.Continuation Sheet(s)SF-LLLA attached: ['Yes ❑ No <br /> 16.tnlonnaeari requested through this form is authorized by title 3i US.C-sedies <br /> 1352 This disclosure of lobbying agWiues is a materi al representation OTfact upon Signature: <br /> which reliance was placed by the tier 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 /> information will be reported to the Congress semi-annually and will be available for <br /> public inspection Any person who fails to file the required disclosure shall be subject Title: <br /> to a dvif penalty of not less that$10,000 and not more than 5100,000 for each auch — <br /> failure. Telephone No.: Date: <br /> '� c.� �,:. � � � Authorized far Local Reproduction <br /> si r - Standard Form LLL(Rev.7-97) <br />