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DISCLOSURE OF LOBBYING ACTIVITIES Approved byoMs Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-Does (See reverse for public burden disclosure.) 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 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 ^ subawaraee and Address of Prime: Tier_ __, if known: Con ressional District, if known: Con ressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, ifapplicable: _______ 8. Federal Action Number, if known: 9. Award Amount, ifknown: 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (ifindividual, last name, first name, MI): different from No. l0a) (lastname, first name, MI): (attach Continuation Shee t(s) SF-LLLA, i/necessary) 11. 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. wntingent 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: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ^ vas ^ No 16. Inlamation ragaa.tea Mrough Mis Iprtn .s apMprlietl br ena 3a u.s.c. sadion 1352 This tlisdosure of bbbying adivNas Is a materiel re rosentafion of fad Signature: . p upm whkh reliance was plecetl by the tier abeva when this bensacgon was matle or enteretl into. This tlisdosure is requ'vetl pursuant M 31 U 1352 This S C Print Name: . . . . iMertnafion will be reportetl to Me Congress semi-annualty antl will be availade for Titl puWk inspndion. My person who fails b file Me requiretl tlistlosure shall be e: subjrwi to a dvil panaay"el not bss Nat 510,000 antl rot more Men 5100,000 for aeon wadi l=area. Telephone No.: ________________ Date: Fpderat USe Only: Authorized for Local Reprotluction Stantlard Form LLL (Rev. 7-97)