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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-oo46 (See reverse for Dublic 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 I. 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: Tier __, 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 (if individual, last name, first name, 1141): different from No. 10a) (last name, first name, Ml): (attach Continuation Sheet(s) SF-LLLA, ifnecessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ❑ actual ❑ planned ❑ a. retainer ❑ Is. 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: ❑ res ❑ No 16. inbmanon reyuastad hreagh his ram is a ,sed by nue 31 U.S.C. seCwn Signature: g 1352. This disdowre or abbying acnviaea Is a mahaal represenlanon or fad print Name: upon which reliance was placed by he Hell above when his trcrandiai was mad* a' snared into. This disdocura is required wmant b 31 U.S.C. 1352. This Title: iodnnanon wil be reP stad m he Cagross cemiannualy and will be avWlable for Wbla Inspadson. Any person who rags a NO he required dhidosure anal be Telephone No.: Date: subiad b a ovil penalty d no ass that $10,0o0 and no mea hen simm to aad,sumfalure. n + , e Ude ICD riIq(p Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)