Okaloosa County BOCC — January 19, 2016 — SF-LLL Disclosure of Lobbying — reading text

1-800-518-4726 WORKSPACE FORM SUPPORT@GRANTS.GOV This Workspace form is one of the forms you need to complete prior to submitting your Application Package. This form can be completed in its entirety offline using Adobe Reader. You can save your form by clicking the "Save" button and see any errors by clicking the “Check For Errors” button. In-progress and completed forms can be uploaded at any time to Grants.gov using the Workspace feature. When you open a form, required fields are highlighted in yellow with a red border. Optional fields and completed fields are displayed in white. If you enter invalid or incomplete information in a field, you will receive an error message. Additional instructions and FAQs about the Application Package can be found in the Grants.gov Applicants tab. OPPORTUNITY & PACKAGE DETAILS: Opportunity Number: OVW-2016-9003 Opportunity Title: OVW FY 2016 Justice for Families Program Opportunity Package ID: PKG00219779 CFDA Number: 16.021 CFDA Description: Justice Systems Response to Families Competition ID: OVW-2016-9003 Competition Title: OVW-2016-9003 Opening Date: 11/24/2015 Closing Date: 01/21/2016 Agency: Office on Violence Against Women Contact Information: Carrie Mitchell E-mail: OVW.JFF@usdoj.gov Phone: 202-307-6026 APPLICANT & WORKSPACE DETAILS: Workspace ID: WS00002018 Application Filing Name: Okaloosa County Board of County Commissioners DUNS: 6132776490000 Organization: OKALOOSA, COUNTY OF Form Name: Disclosure of Lobbying Activities (SF-LLL) Form Version: 1.1 Requirement: Mandatory Upload Count: 0 Download Date: 01/06/2016 Form State: No Errors FORM ACTIONS:  DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 0348-0046 1. * Type of Federal Action: 2. * Status of Federal Action: 3. * Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award d. loan e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: Prime SubAwardee Tier if known: * Name Safe Connections * Street 1 Street 2 PO Box 436 * City State Zip Shalimar FL: Florida 32579 Congressional District, if known: 5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime: * Name Okaloosa County Board of County Commissioners * Street 1 Street 2 302 North Wilson Street, Suite 302 * City State Zip Crestview FL: Florida 32536 Congressional District, if known: 6. * Federal Department/Agency: 7. * Federal Program Name/Description: US Department of Justice,OVW Justice Systems Response to Families CFDA Number, if applicable: 16.021 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Registrant: Prefix * First Name Middle Name N/A * Last Name Suffix N/A * Street 1 Street 2 * City State Zip b. Individual Performing Services (including address if different from No. 10a) Prefix * First Name Middle Name N/A * Last Name Suffix N/A * Street 1 Street 2 * City State Zip 11. 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 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 * First Name Middle Name Mr. Charles K. * Last Name Suffix Windes Jr. Title: Chairman Telephone No.: 850-689-5030 Date: Authorized for Local Reproduction Federal Use Only: Standard Form - LLL (Rev. 7-97)