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DISCLOSURE OF LOBBYING AC1,MT1EjS <br />COMPLETE THIS FORM TO DISCLOSE LOB$Y1N:G ACTTV1TiF.,q Pi rn cT t AMT -rn 21 TT 0 <br />1. Type of Federal Action: <br />=a. contract <br />b, grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />2. Status of Federal Action: <br />a. bid/offer/application <br />b. initial award <br />c: post -award <br />4. Name and Address of Reporting Entity <br />Prime Subawardee <br />Tier , if known <br />Congressional District, if known <br />b. Federal Department/Agency: <br />8. .Federal Action Number, if known; <br />10. it. Name and Address of Lobby Entity <br />(If individual, last name, first name, Ml) <br />3. Repart Type: <br />a. initial <br />b. material change <br />For Material Change Only: <br />Year— quarter <br />date of last report _ <br />5. If Reporting Entity In No. 4.is Subawardee, <br />Enter Name and Address of Prime: <br />Congressional District, if brown <br />7. Federal Program Name/Description: <br />CFDA Number, ifapl1leahic, <br />9. Award Amount, if known: <br />b. Individuals Performing Services: (including <br />address if different from No. I oa) <br />(last name, first name, MI) <br />(attach Continuation Sheet(s) if necessary) <br />11. Amount of Payment (check all that apply) 1.3. Type. of Payment (check all that apply) <br />S�. ❑ actual E] planned a. retainer <br />b. one-limc fec <br />12, Form of Payment (check all that apply): o. commission <br />a. cash d. contingent fee <br />qb. in-kind; specify: nature a deferred <br />value _ f other, specify <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including <br />officer(s), employee(,), or member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) ifnecessary) <br />15. Continuation Sheet(s) attached: Yes ❑ No <br />16, Wbrmation requested through this form is anthnriZed by <br />Title 31 U,S.C. Section 1352. This disclosure of lobbying <br />reliance was placed by the day above when his transaction <br />WAS made or catered into. This disclosure is rcquirad <br />pursuant to 31 US.C. 1352. 'Phis information, will be <br />reported. to Congress semiannually and will be available for <br />public inspection. AAA person w110 Fails rn f}ln the required <br />disclosure shall be subject to a civi[ penalty of not less than <br />$10,000 and not more than $100,000 for cath such failure. <br />Federal Use <br />Signature: <br />Print Name: <br />Title: <br />Telephone No.: Date: <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />BID FORMS <br />REDWOOD CITY PAVEMENT PRESERVATION PROJECT 00400-11 <br />