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California Department of Public Health - Special Terms and Conditions Exhibit D(F) <br /> Attachment 2 <br /> CERTIFICATION REGARDING LOBBYING a <br /> � Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 o�e�ao� <br /> (See reverse for public burden disclosure) � � <br /> 1. Type of Federal Action: 2. Status of Federal Action: � 3: Report Type: <br /> [] a. contract [] a. bid/offer/application []. a, initialfiling . <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Onty: � � <br /> d. loan <br /> e. loanguarantee Year_quarter_ . <br /> f. loan insurance date of Iast report _ <br /> 4. Name anA Address of Reporting Entity: ��f Reporting Entity in No. 4 is Subawardee, Enter Name <br /> j and Address of Prime: <br /> ❑ Prime �] Subawardee . <br /> Tier _, if known: <br /> Con ressional Distric� If known: Con ressional District, If known: <br /> 6. Federal DepartmenUAgency � — �7. Federal Program NamelDesr.ription: � <br /> � � I CDFA Number, if appiicable: _ <br /> 8. Federal A.ction�NUm6er, if knowre 9. Award Amount, if known: � <br /> I $ <br /> . 10:a. Name and Address of Lobbying Registrant o. Individuals Performing Services (�ncluding add2ss if different from <br /> � pf individual, /as: name, first namP, .Mli� IOa. <br /> (Last name, Fiist name, MIJ: <br /> I <br /> � <br /> � <br /> � <br /> i <br /> i l�. Informa[ion reGuested through th�s form is authorized 6y :itle 31 <br /> . .�� U S.C. sec[iori 1352. This tlisclosure of lobbyng acxivi5es is a matenal �Signatu�e: :__ __ ___ _ <br /> . representatior. cf fact upon which relianoe was p!aced oy [ne tier . <br /> � . above when this Vansaction was made or entered into. Th�s Print Name: ____ __ ____ _ <br /> disr,losure is required �i U.�q .�352. This infoimation Title: <br /> wi�l be available for ubf�c ins edion. re �iretl disclasure shal; be � <br /> . sub�ect [o a not more than $700,000 for each sucl� fai�ure. Telephone No.: Da!e��. <br /> I. <br /> � � � �� � � � - <br /> � S �, . � � � Authorized for Local Reproduction <br /> �,�,. =,�.,.�� ��: � � �'3• '� � �, -���� - � Standard Form-LLL (Rev. 7-97) . <br /> t�� _. f#9"xh _ _ 0ax __' _ <br /> CDPH Exhibit D(F) (8/10) � Page 24 of 25 <br />