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"isclosure of Lobbying ActiV- 1s <br />Complete tnls form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br />1. Type of Federal Action <br />❑a. contract <br />b. grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />2. Status of Federal Action <br />❑a. bid/offer/application <br />b. initial award <br />c. post -award <br />4. Name and Address of Reporting Entity <br />❑Prime ❑ Subawardee Tier , if known: <br />Congressional District, if known <br />6. Federal Department/Agency <br />6. Federal Action Number, if known <br />10a. Name and Address of Lobbying Registrant <br />(if individual, last name, first name, MI) <br />11. Amount of Payment (check all that apply) <br />$ n actual <br />12. Form of Payment (check all that apply) <br />❑ a. cash <br />❑ b. in -kind; specify., nature <br />value <br />continuation <br />planned <br />Approved by OMB 0348-0046 <br />3. Report Type <br />❑a. initial filing <br />b. material change <br />For Material Change Only <br />year (yyyy) quarter <br />date of last report (mm/dd/yyyy) <br />5. If Reporting Entity in No. 4 is Subawardee, enter Name and Address <br />of Prime <br />Congressional District, if known <br />7. Federal Program Name/Description <br />CFDA Number, it applicable <br />9. Award Amount, it known <br />b. In dividualaPerforming$ervices(induding address if different from No, foa.) <br />(last name, first name, MI) <br />heet(s) if necessary) <br />13. Type of Payment (check all that apply) <br />a. retainer <br />b. one-time fee <br />❑ c. commission <br />❑ d. contingent fee <br />e. deferred <br />f. other (specify) <br />i4, nnet uescription of services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, <br />for Payment Indicated in item 11 <br />continuation <br />15. Continuation sheets attached Yes ❑ No <br />iu.irnurmduon requestea inrougn tnis torm is authorized by Sec.319, <br />Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- <br />65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />is a material representation of fact upon which reliance was placed <br />by the above when this transaction was made or entered into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. This information <br />will be 'reported to the Congress semiannually and will be available <br />for public inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less than $10,000 <br />and not more than $100,000 for each such failure, <br />if necessary) <br />Signature <br />Print Name' <br />Title <br />Telephone, No. <br />Date (mm/dd/v <br />T�_ { Authorized for Local Reproduction <br />_ I Standard Form-LLL (7/97) <br />ATTACHMENT I TO EXHIBIT C PAGE ,I of 2 <br />