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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 I-1a. 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 ❑ Subawardee and Address of Prime: Tierifknown: 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 (if individual, last name, first name, Ml): different from No. 10a) (last name, first name, MI): (attach Continuation Sheets) 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 Contnuation Sheets) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16.Informagon requested Mmugh we form Is aWhorz by title 31 U.S.C. sedmn 1352. This disdosure of lobbying adhAss is a material rawasentatlon a fad Signature: Print Name: upon which reliance was placed by the liar above when we bansacion was made or entered into. This disdosura is required pumuanl lo 31 U.S.C. 1352. This information will be reported to we Congress semiannually and will be available for public inspedion. AM parson who fails to file Me required disdosum shall be Title: subject b a dull penally of not less Mal $10,000 aM not more than $100,000 for each su,b fa"ure. Telephone No.: ___------------------ Date: Federal Use Only: Authorized for Local Reproduction Stantlartl Form LLL(Rev. 7-97)