Fld Name /
Item No.

Instruction

1

Type of Federal Action

Enter the Type of Federal Action, by letter (a – f), in the box.

2

Status of Federal Action

Enter the Status of Federal Action, by letter (a – c), in the box.

3

Report Type

Enter the Report Type, by letter (a – b), in the box.

If this is a follow up report caused by a material change to the information previously reported:

• Enter the year and quarter in which the change occurred
• Enter the date of the last previously submitted report by this reporting entity for this covered Federal action.

4

Name and Address of Reporting Entity

Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Enter the tier of the subawardee, e.g., the first subawardee of the prime is the 1^st tier.

Enter the full Name and Address (street address, city, State, and zip code) of Reporting Entity. Include Congressional District, if known.

5

Name and Address of Prime, if Subawardee

If "Subawardee" is checked, enter the full name, address, city, State, and zip code of the prime Federal recipient, including the Congressional District, if known.

6

Federal Department or Agency

Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below the agency name, if known.

7

Federal Program Name or Description

Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8

Federal Action Number

Enter the most appropriate Federal identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal (RFP) number; Invitation for BID (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency).

9

Award Amount

Enter the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5, if there has been an award or loan commitment by the Federal agency.

10

Name and Address of Lobbying Registrant

Item 10a. Enter the full name, address, city, State, and zip code of

the lobbying registrant under the Lobbying Disclosure Act

of 1995 engaged by the reporting entity identified in Item 4

to influence the covered Federal action.

Item 10b. Enter the full names (last name, first name, and middle

initial) of the individual(s) performing services, and include

full address if different from 10a.

11

Signature

Signature: Enter the signature of the certifying official.

Name: Print the full name of the certifying official.

Title: Enter the title of the certifying official.

Telephone: Enter the telephone number (Include Area code) of the

certifying official.

Date: Enter the date the form is signed by the certifying official.

If you are mailing or faxing this form, print the form and enter the

Signature of an authorized individual, i.e., a corporate officer, partner,

or proprietor. If this form is approved for electronic transmission and

you have established credentials with USDA to submit forms

electronically, use the buttons provided on the form for transmitting the form to the Kansas City Commodity Office.