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<br />1. Type of Federal Action:
<br />D a. contract
<br />b. grant
<br />c. cooperative agreement
<br />d.loan
<br />e. loan guarantee
<br />f. loan insurance
<br />4. Name and Address of Reporting Entity:
<br />0 Prime 0 Subawardee
<br />Tier ---' ifknown:
<br />
<br />DISCLOSURE OF LOBBYING ACTIVITIES
<br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
<br />See reverse for ublic burden disclosure.
<br />2. Status of Federal Action: 3. Report Type:
<br />Da. bid/offer/application D a. initial filing
<br />b. initial award b. material change
<br />c. post-award For Material Change Only:
<br />year ------ quarter -----
<br />date of last report --------
<br />
<br />Approved by OMB
<br />0346-0046
<br />
<br />5. If Reporting Entity in No.4 is a Subawardee, Enter Name
<br />and Address of Prime:
<br />
<br />Con ressional District, if known:
<br />6. Federal Department/Agency:
<br />
<br />Con ressional District, if known:
<br />7. Federal Program Name/Description:
<br />
<br />CFDA Number, if applicable: ------
<br />
<br />8. Federal Action Number, if known:
<br />
<br />9. Award Amount, if known:
<br />
<br />$
<br />
<br />10. a. Name and Address of Lobbying Entity
<br />(if individual, last name, first name. M/):
<br />
<br />b. Individuals Performing Services (Including address if
<br />different from No. 10a)
<br />(last name, first name, M/):
<br />
<br />(affach Continuation Sheet(s) SF-LLLA. if necessary)
<br />11. Amount of Payment (check a/I that apply): 13. Type of Payment (check all that apply):
<br />
<br />$ ------
<br />
<br />0 actual
<br />
<br />0 planned
<br />
<br />0 a. retainer
<br />0 b. one-time fee
<br />0 c. commission
<br />0 d confngentlee
<br />
<br />12. Form of Payment (check all that apply):
<br />Oacash
<br />
<br /> I
<br />0 b. in-kind; specify: nature ------- 0 e. deferred
<br /> value -------- 0 f. other; specify: ---------------
<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 Conünuaüon Sheet(s) SF-LLLA. if necessary)
<br />15. Continuation Sheetlsl SF-LLLA attached: DYes DNa
<br />16 "'~m"km .oq,~"d thro"h thl, """' " "'If""'" by"" 31 U.S.C. ,""'" Signature:
<br />'1352,ThI'dI'cl""""""'byl""""~I"m"MI""p"",,,'~oIl'ct
<br />""",whloh "11,""w.. pi"", bylh.II..,b".wh~ thl,"""""" w~ m,d. Print Name:
<br />oc~""dl,to. ThI,dI,d'~""""""'p,~~","'31U.S.C.1352. ThI,
<br />,','~"" will "",on'" to tho COCO""" "ml-,""",I~ ,"d oM" b. ao,"'" loc Title:
<br />p""""""""".""y"=,wh""""""""""""do.,,,,,"',""
<br />~bj'" to ""ll """,, 0100' I." th,'$1O.OOO ~d oo'm", ""', $100.000"'.
<br />.""",hr."",. Telephone No.: Date:
<br />Federal Use Only: I Authorized for Local Reproduction
<br /> Standard Form LLL (Rev. 7-97)
<br />
<br />
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