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Get AHRQ Standard Form-LLL

Federal Use Only Signature Print Name Title Telephone No. Date Authorized for Local Reproduction Standard Form - LLL EF. 15. Continuation Sheet s SF-LLL-A 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. A. Name and Address of Lobbying Entity if individual last name first name MI Individuals Performing Services including address of different from No. 10a. last name first name MI attach Continuation Sheet s SF-LLL-A if necessary 11. Amount of Payment check all that apply 13. Type of Payment check all that apply a. retainer actual planned b. one-time fee c. commission 12. Form of Payment check all that apply d. contingent fee a. cash e. deferred b. Approved by OMB 0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U*S*C. 1352 See reverse for public burden disclosure. Type of Federal Action a* b. c* d. e. f* Status of Federal Action contract grant cooperative agreement loan loan guarantee loan insurance a* bid/offer/application b. initial award c* post-award Name and Address of Reporting Entity Prime Subawardee Tier Report Type a* initial filing b. material change For Material Change Only Year Quarter date of last report If Reporting Entity in No* 4 is Subawardee Enter Name and Address of Prime if known Congressional District if known 6. Federal Department/Agency Federal Program Name/Description Federal Action Number if known CFDA Number if applicable Award Amount if known 10. a* Name and Address of Lobbying Entity if individual last name first name MI Individuals Performing Services including address of different from No* 10a* last name first name MI attach Continuation Sheet s SF-LLL-A if necessary 11. Amount of Payment check all that apply 13. Type of Payment check all that apply a* retainer actual planned b. one-time fee c* commission 12. Form of Payment check all that apply d. contingent fee a* cash e. deferred b. in-kind specify nature f* other 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. 15. Continuation Sheet s SF-LLL-A 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 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 than 10 000 and not more than 100 000 for each such failure. Approved by OMB 0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U*S*C. 1352 See reverse for public burden disclosure. Type of Federal Action a* b. c* d. e. f* Status of Federal Action contract grant cooperative agreement loan loan guarantee loan insurance a* bid/offer/application b. .

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