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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, 1 352 0348-0046 <br /> See reverse for •ublic burden disclosure. <br /> = ,Type of Federal Action: .2. Status of Federal Action: 3. Report Type: <br /> a. contract •a. bid/offer/application L! a. initial filing <br /> • b. grant L.-- 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 <br /> date of last report <br /> f- loan insurance <br /> ••% 1 ✓ i•� +-- � •-•l•• 1 —.l t +•• � fir• . <br /> 4. Name and Address of Reporting Entity: 15. 1f I eporting Entity in No.4 is a Subawardee, Enter Name <br /> ❑Prime ❑Subawardee and Address of Prime: <br /> Tier if known: <br /> OBE COUNTY <br /> 200 SOUTH CAMERON TREET <br /> HILLSBOROUGH,NC 27278 <br /> Con I ress i n l District,if known: 0 • on r s io n i.District,if known: <br /> 6. Federal Department/Agency: 7. Federal Program IamelDes ription: <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 /> (f individual, last name, first name, MO: different from No. 10a) <br /> (last name, first name, MI): <br /> ——\ .. +•a--'--�e,� +--••�•FR +-•a-�� --••r. 1_ aa.�� �4+�r� ++��, r-FN--4r <br /> 11.Amount of Payment(check all that apply): 13.Type of Payment(check all that apply) <br /> ❑actual Li planned LI a.retainer <br /> Db.one-timefee <br /> 112. Form of Payment(check all that apply): ❑c.commission <br /> D a.cash Ed,contingent f <br /> ❑b.-in-kind;specify:nature fle.deferred <br /> value f.other;specify: <br /> ..r. <br /> Brief escr i tion of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s),or <br /> Ikeranber(s)contacted,for Payment Indicated in Item 71 <br /> B ENTERPRISE GRANT S <br /> ,. tech antinuaron Sheep s SP-LLLA,if nec sa <br /> 15.*Continuation Feet( F-t.L.LA attached: Yes No Y <br /> I 6 1 nfarmatica requested through this form is authorized by GEte 31 U•S•C.section, ' <br /> I X52.This disclosure of lobbying activles i$a material representation of fact upon Signature: <br /> Which reliance wa$placed by the tier above when this transaction was made or <br /> entered into This diacfosure is rewired pursuant to 31 U-S.C.7 362 This Print Name: <br /> inforrnabon via be reported to the Congress semi-annually and wilt be available for <br /> pubic inspection.Any person who fa ifs to fire the required disclosure shall be subpar( Title: <br /> to s civil penalty of not less that 510.01:10 and not more than$100.0.00 foe each such ��...-..... <br /> • failure- Telephone No.: Date: <br /> iM ` f�y�er'r f i.-;�,fL{S 1_ C=I}Fo'Y'{tn R,.fr r N x 1 y:N L� y u;fr' . t � N <br /> Authorized for Local Rmaeproduc•tion <br /> y ' �o ` <br /> • <br /> Standard Form LLL(Rev,7-97) <br />