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Consolidated Agreement FY21 Page 26 of27
<br />1.
<br />• • • • • •
<br />4.
<br />• •
<br />Disclosure of Lobbying Activities
<br />(Approved by 0MB 0348-0046)
<br />C omplete this f orm to disclose lobbying activities pursuant to 31 U.S.C.1352
<br />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
<br />d. loan For Material Change Only:
<br />e. loan guarantee
<br />f. loan insurance Year Quarter
<br />Date of Last Report:
<br />Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name
<br />Prime and Address of Prime:
<br />Subawardee Tier , (if known)
<br />Congressional District (if known) Congressional District (if known)
<br />6. Federal Department/Agency: 7. Federal Program Name/Description:
<br />CFDA Number (if applicable)
<br />8. Federal Action Number (if known) 9. Award Amount (if known) :
<br />$
<br />10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
<br />(if individual, last name, first name, Ml): different from No. 10a.) (last name, first name, Ml):
<br />(attach Continuation Sheet(s) SF-LLL-A, if necessary) (attach Continuation Sheet(s) SF-LLL-A, if necessary)
<br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply):
<br />$ actual planned • a. retainer • b. one-time fee
<br />12. Form of Payment (check all that apply): • C. commission • d. contingent fee
<br />• a. cash • e. deferred
<br />• b. In-kind; specify: Nature • f. other; specify:
<br />Value
<br />14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or
<br />Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheet(s) SF-LLL-A, if necessary):
<br />15. Continuation Sheet(s) SF-LLL-A attached: •Yes •No
<br />16. Information requested through this form is authorized by Signature: title 31 U. S. C. section 1352. This disclosure of lobbying
<br />activities is a material representation of fact upon which
<br />Print Name: reliance was placed by the tier above when this transaction
<br />was made or entered into. This disclosure is required
<br />pursuant to 31 U.S. C. 1352. This information will be Title:
<br />reported to the Congress semi-annually and will be
<br />available for public inspection. Any person who fails to file Telephone No: Date:
<br />the required disclosure shall be subject to a civil penalty of
<br />not less than $10,000 and not more than $100,000 for each
<br />such failure.
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<br />Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing
<br />data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate
<br />or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction
<br />Proiect (0348-0046), Washington, D. C. 20503
<br />DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
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