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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-o048 .~ee reverse for public burden disclosure. 1. Type of Federal Action: ~. Status of Federal Action: 3.' Report Type: a. contract Ma. bid/offer/application ~ a. initial filing Nb. grant ' 'b. initial award ' ' b. material change c. cooperative agreement c. post-award For Material Change Only: d. loan year ...... quarter ....... e. loan guarantee date of last report f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name [] Prime [] Subawardee and Address of Prime: Tier ....... if known: Con~lressional District, if known: Congressional District, if known: 6. Federal DepartmentJAgency: 7. Federal Program Name/Description: CFDA Number, if applicable: 8. Federal Action Number, if known: 9. Award Amount, if known: $ ! 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. l Oa ) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLLA. if necessary) 1'1. Amount of Payment (check all that apply): ~13. Type of Payment (check all that apply): $ [] actual [] planned [] a. retainer [] b, one-time fee 12. Form of Payment (check all that apply): [] c. commission [] a, cash [] d. contingent fee [] b. in-kind: specify: nature [] e. deferred value [] f. other; specify: 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (a~tach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: [] Yes [] No 16 rn~m,t~n r~,~*d through Ibls f~rrn is authc~zed by title 31 U.S.C+ $~cfion Signature: ..~h ,~ ~,.r.. Telephone No.: Date: Federal Use Only: I Authorized for LocaIRepmduction I Standard Form LLL (Rev, ;'-97)