t report ______
4. Name and Address of Reporting Entity:
Prime Subawardee
Tier____, if known:
Congressional District, if known:
5. If Reporting Entity in No. 4 is Subawardee,
Enter Name and Address of Prime:
Congressional District, if known:
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number, if applicable: __________
8. Federal Action Number, if known:
9. Award Amount, if known:
$
10. a. Name and Address of lobbying registrant
(if individual, last name, first name, MI):
b. Individuals performing services (including
address, if different from No. 10a)
(last name, first name, MI):
16. Information requested through this form is
authorized 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 when
this 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 will be
available 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 more than $100,000
for each such failure.
Signature: _______________________________________
Print Name: ______________________________________
Title: ___________________________________________
Telephone No.: ____________________ Date:_________
Federal Use Only:
Authorized for Local Reproduction
Standard Form - LLL INSTRUCTIONS FOR COMPLETION OF DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee
or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C.
section 1352. The filing of a form is required for each payment or agreement to
make payment to any lobbying entity for influencing or attempting to influence an
officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with a covered
Federal action. Complete all items that apply for both the initial filing and
material change report. Refer to the implementing guidance published by the Office
of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is
and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow-up
report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal
action.
4. Enter the full name, address, city, state and zip code of the reporting entity.
Include Congressional District, if known. Check the appropriate classification
of the reporting entity that designates if it is, or expects to be, a prime or
subaward recipient. Identify the tier of the subawardee, e.g., the first
subawardee of the prime is the 1st tier. Subawards include but are not limited
to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee", then enter
the full name, address, city, state and zip code of the prime Federal recipient.
Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment.
Include at least one organizational level below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action
(item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA)
number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal
action identified in Item 1 (e.g., Request for Proposal (RFP) number, Invitation
for Bid (IFB) number, grant announcement number, the contract, grant, or loan
award number; the application/proposal control number assigned by the Federal
agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by
the Federal agency, enter the federal amount of the award/loan commitment for
the prime entity identified in item 4 or 5.
10. (a)Enter the full name, address, city, state and zip code of the registrant,
under the Lobbying Disclosure Act of 1995, engaged by the reporting entity
identified in item 4 to influence the covered Federal action. (b)Enter the full names of the individual(s) performing services, and include
full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).
16. The certifying official shall sign and date the form, print his/her name,
title, and telephone number.
Public reporting burden for this collection of information is estimated to average
30 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding the burden
estimate or any other aspects of this collection of information, including
suggestions for reducing this burden, to the Office of Management and Budget,
Paperwork Reduction Project (0348-0046), Washington, D.C. 20503. PART
________ - NEW RESTRICTIONS ON LOBBYING
Subpart A - General
Sec.
___.100 Conditions on use of funds.
___.105 Definitions.
___.110 Certification and Disclosure.
Subpart B - Activities by Own Employees.
___.200 Agency and legislative liaison.
___.205 Professional and technical services.
___.210 Reporting.
Subpart C - Activities by Other than Own Employees
___.300 Professional and technical services.
Subpart D- Penalties and Enforcement
___.400 Penalties.
___.405 Penalty procedures.
___.410 Enforcement.
Subpart E - Exemptions
___.500 Secretary of Defense.
Subpart F- Agency Reports
___.600 Semi-annual compilation.
___.605 Inspector General report.
Appendix A to Part ___ - Certification Regarding Lobbying
Appendix B to Part ___ - Disclosure Form to Report Lobbying
Appendix C to Part ___ - Contract Clause
Authority: Section 319, Public Law 101-121 (31 U.S.C. 1352)
(citation to Agency rulemaking authority); as amended by sec. 10, Public
Law 104-65.
Subpart A - General
___.100 Conditions on use of funds.
(a) No appropriated funds may be expended by the recipient of a Federal contract,
grant, loan, or cooperative agreement to pay any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress,
an officer or employee of Congress, or an employee of a Member of Congress in
connection with any of the following covered Federal actions: the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan,
the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement.
(b) Each person who requests or receives from an agency a Federal contract, grant,
loan, or cooperative agreement shall file with that agency a certification, set
forth in Appendix A, that the person has not made, and will not make, any payment
prohibited by paragraph (a) of this section. (c) Each person who requests or receives from an agency a Federal contract, grant,
loan, or a cooperative agreement shall file with that agency a disclosure form, set
forth in Appendix B, if such person has made or has agreed to make any payment
using nonappropriated funds (to include profits from any covered Federal
action), which would be prohibited under paragraph (a) of this section if paid for
with appropriated funds.
(d) Each person who requests or receives from an agency a commitment providing for
the United States to insure or guarantee a loan shall file with that agency a
statement, set forth in Appendix A, whether that person has made or has agreed to
make any payment to influence or attempt to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with that loan insurance or guarantee.
(e) Each person who requests or receives from an agency a commitment providing for
the United States to insure or guarantee a loan shall file with that agency a
disclosure form, set forth in Appendix B, if that person has made or has agreed to
make any payment to influence or attempt to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with that loan insurance or guarantee.
___.105 Definitions.
For purposed of this part:
(a) Agency, as defined in 5 U.S.C. 552(f), includes Federal executive departments
and agencies as well as independent regulatory commissions and Government
corporations, as defined in 31 U.S.C. 9101(1).
(b) Covered Federal action means any of the following Federal actions:
(1)
The awarding of any Federal contract;
(2)
The making of any Federal grant;
(3)
The making of any Federal loan;
(4)
The entering into of any cooperative agreement; and,
(5)
The extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan or cooperative agreement.
Covered Federal action does not include receiving from an agency a commitment
providing for the United