Name and of Official Signing for Organizational Entry Telephone No. Of Signing Official Signature of Official Date Signed ATTACHMENT H-2 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Type of Federal Action: Status of Federal Action: Report Type: Contract Bid/offer/application Initial filing Grant Initial award Material change Cooperative Agreement Post-award Loan For Material Change Only: Loan guarantee Year quarter Loan insurance Date of last report 4. Name and Address of Reporting Entity: If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime: Prime Subawardee Tier , if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: if known: if known: 8. Federal Action Number, 9. Award Amount, $ 10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. 10a) (last name, first name, MI): 11. Amount of Payment (check all that apply) 13. Type of Payment all that apply) $ actual planned a. retainer 12. Form of Payment (check all that apply) b. one-time c. commission a. cash d. contingent fee b. in-kind; specify: nature e. deferred f. specify: value 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: Yes No 16. Information requested through this form is authorized by title 31 U.S.C. Section 1352. This disclosure of lobbying activities is a material Signature: ___________________________________ representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure Print Name: is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the required
Name and of Official Signing for Organizational Entry Telephone No. Of Signing Official Signature of Official Date Signed ATTACHMENT H-2 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Type of Federal Action: Contract Grant Cooperative Agreement Loan Loan guarantee Loan insurance Status of Federal Action: Bid/offer/application Initial award Post-award Report Type: Initial filing Material change For Material Change Only: Year quarter Date of last report 4. Name and Address of Reporting Entity: Prime Subawardee Tier , if known: Congressional District, if known: If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address of Prime: 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 (including address if different from No. 10a) (last name, first name, MI): 11. Amount of Payment (check all that apply) $ actual planned 13. Type of Payment all that apply) a. retainer b. one-time c. commission d. contingent fee e. deferred f. specify: 12. Form of Payment (check all that apply) a. cash b. in-kind; specify: nature value 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: Yes No 16. 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 or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be available for public inspection. Any person who fails to file the required Signature: ___________________________________ Print Name:
OHEP%20RFP%202014-DBM%20FINAL%20v.91814.docx