Page 7

Official source

DISCLOSURE OF LOBBYING ACTIVITIES ome Control Number: 4040-0013 Expiration Date: 2/28/2025 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

[Review Public Burden Disclosure Statement|

1. * Type of Federal Action: 2. * Status of Federal Action: 3. * Report Type: a. contract [] a. bidiotter/appiication a. initial filing DX] b. grant DX]. initia! award [_] ©. material change [_] ¢. cooperative agreement [7] « postiaward

[_] 4. toan

[_] e.toan guarantee [_] «. toan insurance

4. Name and Address of Reporting Entity:

DX]rrime [_]subawardee Tier if known: [al

“Name [Atabana Department of Public Health Taal]

* Street 1 [202 Monroe Street ] Street 2 [suite 1300 al “City [uontaonery al State pps nlanane ] Zip fe1oa-a771 | Congressional District, if known: px-002 ft

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

6. * Federal Department/Agency: 7. * Federal Program Name/Description:

pospa Food and) Mutation: Bemyice | Special Supplemental Nutrition Program for Women, Infants, and CFDA Number, if applicable: fio.ss7 al

8. Federal Action Number, if known: 9. Award Amount, if known:

5AL700W1003 $

10. a. Name and Address of Lobbying Registrant:

Prefix Lo] * First Name fix | Middle Name “a * Last Name pa | Suffix [ * Street 1 [ ial Street 2 le oe | * City State = Zip L en bes ]

b. Individual Performing Services (including address if different from No. 10a)

Prefix aa “FirstName i7a "] Maite Name ]

* Last Name fra ] Suffix | ]

* Street 1 | ] Street 2 [ or "City [ ] State | ‘| 7. eam |

Information peqeeed 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 the 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.

* Signature:

*Name:

Prefix L * First Name Middle Name [

* Last Name fiarris il Suffix fe ]

State Health officer __| Telephone No. [ 334-206-5200 Joate: [ S/24 fan 24, |

STANDARD FORM LLL (REV. 7/1997) Authorized for Local Reproduction

Page 7

Official source

DISCLOSURE OF LOBBYING ACTIVITIES ome Control Number: 4040-0013 Expiration Date: 2/28/2025 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352

[Review Public Burden Disclosure Statement|

[_] 4. toan

[_] e.toan guarantee [_] «. toan insurance

4. Name and Address of Reporting Entity:

DX]rrime [_]subawardee Tier if known: [al

“Name [Atabana Department of Public Health Taal]

* Street 1 [202 Monroe Street ] Street 2 [suite 1300 al “City [uontaonery al State pps nlanane ] Zip fe1oa-a771 | Congressional District, if known: px-002 ft

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

6. * Federal Department/Agency: 7. * Federal Program Name/Description:

pospa Food and) Mutation: Bemyice | Special Supplemental Nutrition Program for Women, Infants, and CFDA Number, if applicable: fio.ss7 al

8. Federal Action Number, if known: 9. Award Amount, if known:

5AL700W1003 $

10. a. Name and Address of Lobbying Registrant:

Prefix Lo] * First Name fix | Middle Name “a * Last Name pa | Suffix [ * Street 1 [ ial Street 2 le oe | * City State = Zip L en bes ]

b. Individual Performing Services (including address if different from No. 10a)

Prefix aa “FirstName i7a "] Maite Name ]

* Last Name fra ] Suffix | ]

* Street 1 | ] Street 2 [ or "City [ ] State | ‘| 7. eam |

* Signature:

*Name:

Prefix L * First Name Middle Name [

* Last Name fiarris il Suffix fe ]

State Health officer __| Telephone No. [ 334-206-5200 Joate: [ S/24 fan 24, |

STANDARD FORM LLL (REV. 7/1997) Authorized for Local Reproduction