Individual Performing Services. (including address if different from No. 10 a) (Last name, first name, MI)
Individual Performing Services. (including address if different from No. 10 a) (Last name, first name, MI) Amount of Payment: (check all that apply) $_ __________________________________ Actual Planned Type of Payment: (check all that apply) A. Retainer B. One-Time Fee C. Commission D. Contingency Fee E. Deferred F. Other: (specify) _______________ Form of Payment: (check all that apply) A. Cash Nature ____________ B. In-kind (specify) Value _____________ Brief Description of services performed or to be performed and date(s) of service, including officer(s), employees, or members) contracted for payment indicated in Item 11 . (Attach Continuation Sheets if necessary) Continuation Sheets Attached: Yes No Information requested through this form is authorized by Title 31 U.S.C. Section 1352. The disclosure of lobbying activities is a material representation of fact upon which evidence was placed by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. The information will be reported to the Congress semiannually and will be available for public inspection. Any person who fails to file the required disclosures shall be subject to a civil penalty of no less than $10,000 and no more than $100,000 for each such failure. Signature: __________________________________ Print Name: ________________________________ Title: ______________________________________ Telephone Number: __________________________ Date: _______________________________________ Federal Use Only Authorized for Local Reproduction INSTRUCTIONS FOR COMPLETION OF DISCLOSURE OF LOBBYING ACTIVITIES FORM 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 in 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. Use a Continuation Sheet for additional information if the space on the form is inadequate. 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 (OMB) for additi...
