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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 0348-0046 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 El 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: S. If Reporting Entity in No. 4 is a Subawardee, Enter Name ❑ Prime ❑ Subawardee and Address of Prime: TierI if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 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 (/f individual, last name, first name, MI): different from No. 10a ) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLLA, if 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 ❑ c. commission 12. Form of Payment (check all that apply): ❑ 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: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16 IMwmetion requested through this form is authorized by Was 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact Signature: print Name: upon which reliance was placed by the tier above when Nis transaction was made a entered into. This disdosure is required pursuant to 31 US.C. 1352. This Title: information will be reporuml to the Congress semi-annually and wiN be available for public Inspection. Any person who falls W file the required disclosure strap be subject to a civil penaNy of not less Met $10.000 and not mw00 e Man $IN,0for each such f. ure. Telephone No.: Date: Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)