KATHRYN B. BREWER

Executive Coordinator

RYAN STEPHENSON

Assistant Executive Coordinator

STATE OF OKLAHOMA

DISTRICT ATTORNEYS COUNCIL

421 NW 13th Street, Suite 290 | OKC, OK, 73103

Federal Grants Division

Ph: 405-264-5008

Disclosure of Lobbying Activities: Form A-12

INSTRUCTIONS:

If the applicant DOES NOT conduct lobbying activities, then complete section 11 ONLY. If the applicant conducts lobbying activities, complete this form pursuant to 31U.S.C. 1352.

Organization:	Subgrant/Activity Number:
Section 1: Type of Federal Action	Section 2: Status of Federal Action	Section 3: Report Type
Contract Grant Loan	Cooperative agreement Loan Guarantee Loan Insurance	Bid/Offer/Application Initial Award Post Award	Initial Filing Material Change
For Material Change Only:
Year:	Quarter:	Date of last report:
Section 4: Reporting Entity	Section 5: Reporting Entity is Subawardee
Name and Address of Reporting Entity:	Name and Address of Prime:
Congressional District of Reporting Entity:
Identity of Reporting Entity	Prime	Subawardee
Tier (if known)	Congressional District, (if known):
Section 6: Agency	Section 7: Grant and Description
Federal Department /Agency:	Federal Program Name/Description:
CFDA Number, if applicable:
Section 8: Federal Action Number	Section 9: Award
Federal Action Number, if known:	Award Amount, if known:
Section 10: Lobbying Registrant and Lobbying Individuals
Name and Address of Lobbying Registrant (If individual, last name, first name, MI):	Individuals Performing Services (including address if different from No. 10.) (last name, first name, MI)
Section 11: Attestation of NO lobbying Activity
By checking this box, ___________________________ attests that it does NOT participate in lobbying activities
Typed Name of Authorized Official	Title
Signature	Date

Information requested through this form is authorized by Sec. 319, Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104-65, Stat. 700 (31 U.S.C.1352). This disclosure of lobbing activities is a material representation of fact upon which reliance was placed by the 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 semiannually 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.

Instructions for Completing the Disclosure of Lobbying Activities Form

This form must be completed by the reporting entity, whether it is a subawardee or prime Federal recipient, when initiating or receiving a covered Federal action or if there are material changes to a previously submitted disclosure, as required by Title 31 U.S.C. § 1352. A separate form must be filed for each payment or agreement to pay any lobbying entity that seeks to influence or attempts 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 regarding a covered Federal action.

Type of Federal Action

Indicate the type of covered Federal action related to the lobbying activity. Options include Contract, Grant, Cooperative Agreement, Loan, Loan Guarantee, or Loan Insurance.

Status of Federal Action

Select the current status of the covered Federal action: Bid/Offer/Application, Initial Award, or Post Award.

Report Type

Specify the classification of the report—Initial Filing or Material Change. For Material Change reports, provide the year, quarter, and date of the last previously submitted report.

Reporting Entity Information

Provide the full name and address of the reporting entity, including Congressional District (if known). Indicate whether the reporting entity is a Prime or Subawardee. If a Subawardee, specify the tier (e.g., 1st Tier). Subawards include subcontracts, subgrants, and contract awards under grants.

Prime Federal Recipient (if applicable)

If the reporting entity is a Subawardee, enter the full name and address of the Prime Federal recipient, including the Congressional District (if known).

Federal Agency

Enter the name of the Federal agency making the award or loan commitment, along with one organizational level below the agency, if known (e.g., Department of Transportation, U.S. Coast Guard).

Federal Program Information

Provide the name or description of the Federal program related to the covered Federal action. If known, include the Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, or loan commitments.

Federal Action Identifier

Enter the most relevant identifying number for the Federal action, such as a Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, or contract/grant/loan award number. Be sure to include prefixes (e.g., “RFP-DE-90-001”).

Award or Loan Commitment Amount

If the Federal action involves an award or loan commitment, provide the total amount of the award or loan commitment for the entity listed in Item 4 or Item 5.

Lobbying Registrant Information

(a) Enter the full name and address of the lobbying registrant under the Lobbying Disclosure Act of 1995 who is engaged by the reporting entity.

(b) List the full names of the individual(s) providing lobbying services, including their address if different from Item 10(a). Include the last name, first name, and middle initial (MI).