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California Depar[ment of Public Health - Special Terms and Conditions Exhibit D(F)
<br /> INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
<br /> This disclosure fortn shall be completed by the repoNng entity, wheNer subawardee or prime Federal recipient, at Ihe �initiation or receipt of a covered Federal action, or a
<br /> material change to a previous filing, pursuant to title 31 U.S.C. section 1352, The filinq of a fortn is required for each payment or agreement ro make payment to any lobbying
<br /> entity for inFluencing or attempting to influence an officer or empioyee of any agency, a Mem6er of Congress, an oficer or employee of Congress, or an employee of a Member
<br /> of Congress in connection wiN a coveretl Federel action. Complete ali items Nal appy for bolh the initial fiing an0 matenal change report. Refer to the implementin9 guidance ,
<br /> published by ihe Otfice of Management and Bud9et for additional Infortnalion. �
<br /> i. Identity Ne rype of covered Federal action Porwhich lobbying activiry is and/or has been sewred to influence [he oWCOme of a covered Federai aqion.
<br /> 2. Itlentify ihe status of [he mver?tl Fetleral action.
<br /> 3. Itlentiry the appropriate classification of this report. If this is a follow-up report wusetl by a material c�ange to the information previousty reported, enter the year antl
<br /> quarter in which the change occurred. Enter Ihe date of the last previousN submitted report by lhis reporting entiry for Nis covered�Fetlerel action.
<br /> 4. Enter the full name, address, city, State antl zip cotle of Ihe reporting enlity. Inclutle Congressional Districl, if knowa Check the appmpriate classification of Ihe
<br /> reporting entity that designates if it is, or expectis to he a pdme or subaward recipienl Identify Ihe fier of the subawardee, e.g., ihe frst subawardee of the prime is
<br /> the 1st tiec Subawards include but are not limited to suUcon6acts, subgrants and contract awartls untler grants �
<br /> 5. I! the organaation fling [he report in r[em 4 checks "Subawartlee " lhen enter t�e full name, address, city, 5tate and zip code of the prime Fetleral recipient. Inclutle
<br /> Congressional District, if known. . �
<br /> 6. Enler [he name of the Federal agency making ihe awaN or loao commitment. Inclutle at least one organizational level below agenry name, if knowrt Por example,
<br /> Department of Transporialion, Unite�l Slate: Coast Guartl. �
<br /> 7. En?er the fetleral proyram name or descnption fer the cwereA Federal action (item 1j. If knowq enter Ihe ful! Catalog of Petleral Domestic Assislance (CF�A)
<br /> number for grants, coopeative agreements, Icans, entl loan commitments �
<br /> 8. Enter the most appropnate Federai identifying num6er availa6le tor the Federal action identifed ir� item t(e.g., Request for Proposal (RFP) number, Invitation for 8id
<br /> QFB) number; grant announcement number, the contract, grant, or loan awartl num6er, Me appli�ytion/proposal control number assigned by Ne Federal agency).
<br /> Include p2fxes, e g., "HFP-DE-90-OO1P � '
<br /> � 9. For a covered Federal acfion where there has been an awartl o� loan commltment by ihe Federal agenty, enter ihe Federal amount of the awartl/loan commitment
<br /> for Ihe pnme entiry identified in item 4 or 5. � .
<br /> , s; 10. (a) Enter the full name, adGress, ciry, Sate anC zip code of G1e lo5oying regislrant untler [he Lobbying Disclosure Ac[ ot 1995 engagetl by ihe repoding entity
<br /> � identif.2d in item 4 to influence the coverea Federal a;:ion.
<br /> . ' f,b) Ente� the fa11 names of ihe intlivi:ioa;-,sj pedonrir�y services, and i�clu,ie `ull adtlr::ss if diffzrent From 10 (a). Ent=r Lasl Nair;e, First Name, antl Mitltllz Initial �
<br /> (MI).
<br /> � ? 1, T`�e :erti`ying oRiciai s�zil si4n ar,o.^_=[e V�e fo� �n, prnt hi;/her nzrr�e, fi?le, anC telephone numGer. . � �
<br /> � I-�:Hccording�to eht Fape�work Reddction AuL zs amendeG, no oersons are required to respond to a coliection of Iniormation unless it tlisplays a valiU '
<br /> #(?MB Control Number. The valid OMB control oumber for this information collection is OMB No. 0348-0046. Public reDating burden tor this �
<br /> collectiun ot information is estimated to average 1 J min�tes per response, induding time for reviewing Instructions, searching esisting data sources, �
<br /> I gathering and maintaining the data neede4 ar.d completing ind revieeving the collection of information. Send comments regartling the burden
<br /> ' es6rnat_ or any ether aspect of this coPecticn of informatiun, including suggestions for re0ucing this burtlen, M the Office of Management and
<br /> . Bu6get, Paperv+orh Reduction Project �U348-0046;, VJashi.^.gton, DC 20503. . �
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<br /> COPH Exhibit D(F) (8/10) Page 25 of 25
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