SF-LLL Disclosure of Lobbying Activities

Approved by OMB

DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See reverse for p ublic b urden disclo sure.)
1. Type of Federal Action:

2. Status of Federal Action:

a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance

0348-0046

3. Report Type:

a. initial filing
b. material change

a. bid/offer/application
b. initial award
c. post-award

For Material Change Only:
year ________ quarter _________
date of last report _____________

4. Name a nd Ad dress of Repo rting Entity

5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:

Congressional District, if known:

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, if known:
$

10. a. Name and Address of Lobbying Registrant
(if individual, last name, first name, MI):

b. Individuals Performing Services (includ ing address if
different from No. 10a)
(last name, first name, MI):

11. Information requested through this form is authorized by title 31
U.S.C. section 1352. This disclosure of lobbying activities is a material
representation of fact upon which reliance was placed by the tier above
when this transaction was made of entered into. This disclosure is required
pursuant to 31 U.S.C. 1352. This information will be reported to the
Congress semi-annually and will be available for public inspection. Any
person who fails to file the required disclosure shall be subject to a civil
penalty of not less that $10,000 and not more than $100,000 for each such
failure.

Signature:

Federal Use Only:

Print Name:
Title:
Telephone No:

Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be co mple ted by the rep orting entity, whether subaward ee or prime Federal rec ipient, at the initiation or receipt of a
covered Federal action, or a material change to 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. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance
published by the Office of Manage ment and Bud get for additional information.

1. Identify the type o f covered F ederal action for which lob bying activity is and/or has been secure d to influe nce the outco me o f a
covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information
previously reported, enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report
by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the
appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the
tier of the subawardee, e.g., the first subawardee of the prime is the 1 st tier. Subaward s include but are no t limited to subcontrac ts,
subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks “Subawardee,” then enter the full name, address, city, State and zip code of
the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment,. Include at least one organizational level below
agency name, if known. For example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal
Domestic Assistance (C FDA ) numbe r for grants, coop erative agreem ents, loans, and loan c omm itments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for
Pro posal (RF P) nu mbe r; Invitation for B id (IFB) numb er; gant announcement numb er; the co ntract, grant, or lo an award numb er;
the application/pro posal control num ber assigned by the Federal agency). Include p refixes, e.g., “RFP -DE -90-0 01.”
9. Fo r a covered Federal action where there has b een an award or loan c omm itment b y the Federal agency, enter the Federal
amount of the award/loan commitment for the prime entity identified in item 4 or 5.
10.

(a) Enter the full name, address, city State and zip code of the lobbying registrant under the Lobbying Disclosure Act of
1995 engage d by the reporting entity identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter
Last Name, and M iddle Name (M I).

11. The certifying official shall sign and date the form, print his/her name, title, and telephone numb er.
According to the Pap erwo rk Reduction Act, as amended, no perso ns are required to respo nd to a collection o f informa tion unless it
displays a valid OM B C ontro l Num ber. T he valid OM B contro l numb er for this information collection is OM B N o. 03 48-0 046 . Pub lic
reporting burden for this collection of information is estimated to average 10 minute per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.