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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMa <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br />See reverse for public burden disclosure.) <br /> <br />1. Type of Federal Action: 2. Status of Federal Action: 3.' Report Type: <br />a. contract ~ a. bid/offer/application ~ a. initial filing <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 /> <br />Congressional District, if known: Congressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: <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. l Oa ) <br />(last name, first name, MI): <br />(attach Continuation Sheel(s) SF-LLLA, if 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. deferred <br />value [] f. other; specify: <br /> <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 Continua~on Sheet(s) SF-LLLA, if necessary) <br />t5. Continuation Sheet(s) SF-LLLA attached: [] Yes [] No <br />nfomla6ml requested through this ~3mr is authorized by fire 31 U S C sec6on <br />16 · · ' Signature: <br />1352, This disclosure of lobbying ac~vitles is a material reptesenlation of fac~ <br />or entered into. This disclosure is required pur~uan4 to 31 U.S.C. 1352. This Print Name: <br />o,~h s,~ f~ur.. Telephone No.: Date: <br />Federal Use Only: Authorized for Local Reproduction <br /> Standard Form LLL (Rev. 7-97) <br /> <br /> <br />