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i <br />:closure of Lobbying Activi#' <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br />I ype or vecieral Action <br />❑a. contract <br />b. grant <br />c. cooperative agreement <br />d, loan <br />e. loan guarantee <br />f. loan insurance <br />Approved by OMB 0348-0046 <br />2. Status of Federal Action 3. Report Type <br />❑a. bid/offer/application a. initial filing <br />b. initial award ❑ b. material change <br />c. post -award <br />4. Name and Address of Reporting Entity <br />❑Prime ❑ Subawardee Tier , if known: <br />Congressional District, if known <br />b. I-ederat Department/Agency <br />8. Federal Action Number, if known <br />10a. <br />name and Address of Lobbying Registrant <br />(if individual, last name, first name, MI) <br />11. Amount of Payment (check all that apply) <br />$ ❑ actual <br />12. Form of Payment (check all that apply) <br />a. cash <br />b. in -kind; specify: nature <br />value _.. <br />continuation <br />For Material Change Only <br />year (yyyy) - quarter <br />date of last report (mmlddlyyyy) <br />5. If Reporting Entity in No. 41s Subawardee, enter Name and Address <br />of Prime _ <br />Congressional District, if known <br />7. Federal Program Name/Descriptlon <br />CFDA Number, if applicable <br />V. Award Amount, if known <br />b. IndividualsPerformingServiCes(induding address if different from No. loa.) <br />(last name, first name, MI) <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 />14. Brief Description of Services Performed orto be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, <br />for Payment Indicated in Item 11 <br />planned <br />(attach continuation sheet{s} i( <br />15, Continuation sheets attached 1-1Yes❑ Na <br />16. Information requested through this form 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 />Signature <br />Print Name <br />Title <br />Telephone No. <br />Date (mmldd/v <br />,ram .` •�r�_,� Authorized for Local Reproduction <br />Standard Four-LLL (7/97) <br />ATTACHMENT I TO EXHIBIT C -- PAGE I of 2 <br />