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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 oaae-ooas (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 ^ subawardea and Address of Prime: Tier ,ifknown: Con ressional District, ifknown: Con ressional District, ifknown: 6. Federal DepartmenUAgency: 7. Federal Program Name/Description: CFDA Number, if applicable: _________ 8. Federal Action Number, ifknown: 9. Award Amount, ifknown: 10. a. Name and Address of Lobbying Entity b. Individuals Pertorming Services (including address if (if individual, last name, first name, MI): ddferent from No. 10a) (last name, first name, MI ): (attach Contlnuation Shee t(s) SFLLLA, i/necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): ____ ^ actual ^ planned ^ a. retainer ^ b. one-elms 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: J_______, 14. Brief Description of Services Pertormed or to be Pertormed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SFLLLA, i{necessary) 15. Continuation Sheets SF-LLLA attached: ^ vas ^ No 16 l,tlormatlon regaealed Nrgph tlAS form is eutlwdzetl by nna 3t u.s.c. season 1352. Tttls disclosure or bbbylna actlvitlea la a material m eesantation of ied Si nature: g l span which reliance was placed by n,e uv sinus when tltls transaction was made or entamtl ism. This tllsGOSUra is required pursueM b 3t U.S.C 1352 Thk Print Name: . . informa0on will ba reported W Ne Coiproea sem4anrelaly end wiA M availade for pudk iropec0on. Any parson who fHAB N file lha required tlisdocue shag ba Title: subject b e civil penally W riot kas that 510,000 and rmt more Nan 5100,000 for each such hAare. Telephone No.: _________________ Date: i ~7$d8~f ~5~~ Dftl~Et Authorizetl for Local Reprotluction } .. Standard Form LLL (Rev. 7-97)