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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046
(See reverse for public burden disclosure.)
1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
[| a. contract [ bid/offer/application f a. initial filing
b. grant b. initial award ‘—— b. material change
c. cooperative agreement c. post-award For Material Change Only:
d. foan year quarter
e. loan guarantee date of last report
f. loan insurance
4. Name and Address of Reporting Entity:
CO Prime (1 subawardee
Tier , if Known:
Congressional District, if known: 4¢
5. If Reporting Entity in No. 4 is a 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, /f 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):
41, formation requested through this form is euthorized by tlle 31 U.S.C. section
"1352, This disclosure of lobbying zcilvides ts a material representation of fact
upon which reliance wes placed by the tler above when this trensaction was made
or entered Into. This disclosure Is required pursuant to 31 U.S.C. 1352 This
Information will be available for public inspection. Any person who fails to file the
required disclosure shall be subject toa civil penalty ofrotiess than $10,000 and
not more than $109,000 for each suct failure.
Signature:
Print Name:
Title:
Telephone No.: Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)Jump to an indexed page (88 of 88)