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<br />DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 o3as-ooas <br />(See reverse for public burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />^ a. contract ^a. bid/offer/application ~ a. initial fling <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-award For Material Change Only: <br />d. loan year __ __ - _ quarter- - - ___ <br />e. loan guarantee date of last report ______________ <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />^ Prime ^Subawardee and Address of Prime: <br />Tier _____, if known <br />Con ressional District, if known: Con ressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program NamelDescription: <br /> CFDA Number, ifapplicable: _ <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): different from No. l0a ) <br /> (last name, first name, MI ): <br />(attach Continuation Shee t(s) SF-LLLA, i/necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />^ actual ^ planned ^ a. retainer <br /> ^ b. one-time fee <br />12. Form of Payment (check all that apply): ^ c. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind; specify: nature ^ e. deterred <br />value __________ t. other, s eci <br />p N~___ _ _ _ _ _____________ <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) SF-LLLA, iI necessary) <br />15. Continuation Sheets SF-LLLA attached: ^ vas ^ No <br />Information requested through this rortn is auNOdzed by title 31 U.S.C. section <br />18. 1352 <br />This disclosure of lobb <br />in <br />acrmres is a material re <br />r r <br />es <br />ntati <br />t <br />Signature: <br />. <br />y <br />g <br />e <br />on o <br />oo <br />w <br />upon which reliance was placed by the liar above when Nis Gansacdon was matle <br />a enteretl Into <br />This dlsGOSUre is required pursuant to 31 U <br />1352 <br />S <br />C <br />This <br />Print Name: <br />. <br />. <br />. <br />. <br />. <br />information will be reported to the Congress semi-annually antl will be available for <br />Ti <br />l <br />public Inspection. env person who rails m ne the required disclosure shall be t <br />e: <br />subled io a civil penaty of not less that $10,000 and not more than 5100.000 for <br />eam ouch tenure. <br />Telephone No.: ______ Date: <br />Federal Use Only: Authorized for Local Reproduction <br /> Standard Form LLL (Rev. 7-97) <br />