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disclosure of Lobbying Activities <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for instructions and public burden disclosure) <br />Approved by OMB <br />0348-0046 <br />(as amended) <br />1. Type of Federal Action: ~_ 2. Status of Federal Action: _~ 3. Report Type: ~_ <br />a. contract a. bid/offer/application a. initial filing <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-award <br />d. loan For Material Change Only: <br />e. loan guarantee Year: <br />f. loan insurance Quarter: <br /> Date of last report <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter <br />~1 Prime O Subawardee Name and Address of Prime: <br />Tier , if known: <br />City of San Leandro <br />835 East 14th Street <br />San Leandro CA 94577 <br />Congressional District (number), if known: _~ Congressional District (number), if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br />United States Department of Justice COPS in Schools <br />Office of Community Oriented Policing cFDANumber,ifapplicabte: <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br />OMB 1103-0027 $125,000 <br />10. a. Name and Address of Lobbying Registrant 10. b. Individuals Performing Services <br />(if individual, last name, first name, MI): (including address if different from No.l Oa) <br />Slmon & CO. (last name, first name, MI): <br />1660 L St. NW 1050 <br />Washington, D.C. 20036 Len Simon <br />11. Information requested through this form is author- Signature: ~ ` -C~ Cvt <br />ized by Title 31 U.S.C. Section 1352. This disclosure o <br />lobbying activities is a material representation of fact <br />Print Nam • <br />a <br />7 <br />0' M <br />upon which reliance was placed by the tier above whe ear <br />~ <br />.d[Iles <br />this transaction was made or entered into. This disclo <br />sure is required pursuant to 31 U.S.C. 1352. This infor Title: Captain <br />mation will be reported to the Congress semi-annually <br />and will be available for public inspection. Any person <br />who fails to file the required disclosure shall be subje Telephone No.: (~ 10T577-3250 Date: <br />to a civil penalty of not less than $10,000 and not mor <br />than $100,000 for each such failure. <br />Federal Use Only: Authorized for Local Reproduction, Standard Form - LLL <br />