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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <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 />1. Type of Federal Action: <br />2. Status of Federal Action; <br />3. Report Type: <br />❑ a. contract <br />a. bid/offer/application <br />❑ <br />❑ a. initial filing <br />b. grant <br />b. initial award <br />b. material change <br />c. cooperative agreement <br />c. post -award <br />For Material Change Only: <br />d. loan <br />year quarter <br />e. loan guarantee <br />date of last report __--- _______ <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />❑ Prime ❑ Subawardee <br />and Address of Prime: <br />TierI if known: <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable: __________ <br />8. Federal Action Number, if known: <br />9. Award Amount, if known: <br />10. a. Name and Address of Lobbying Entity <br />b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): <br />different from No. 10a) <br />(last name, first name, MI): <br />(attach Continuation Sheets) <br />SF-LLLA, if necessary) <br />11. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply): <br />$ ❑ actual ❑ planned <br />❑ a. retainer I' <br />❑ b. one-time fee <br />❑ c. commission <br />12. Form of Payment (check all that apply): <br />❑ a. cash <br />❑ d. contingent fee <br />❑ b. in -kind; specify: nature <br />❑ e. deferred <br />value <br />❑ 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 Continuation Sheet(s) SF-LLLA, if necessary) <br />15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No <br />16 hdormabon requested Mrough This form is autholvd by ads 31 U.S.C, section <br />1%2. This dacioun re of lobbying scildbes is a material represenlagon of fad <br />Signature: <br />print Name: <br />upon which reliance was placed by Me bar above when this bansecdon was made <br />or entered! in o. This disclosure is required pursuant to 31 J. C. 1%2. This <br />Title: <br />Inherhatbn will be reported M the Congress semi-annually and will be available for <br />inspaogon. <br />public Arty person who fails W file the required disclosure shed be <br />Telephone No.:_ ----- _ Date: <br />subject to a civil penalty of not less Mat so.00o and not more Men 5100.000 for <br />each such failure. <br />Federal Use Only: <br />Authorized for Local Reproduction <br />Standard Form LLL(Rev. 7-971 <br />