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0 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 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 f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name ❑ Prime ❑ Subaivardee 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, ifapplicable: 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, Ml ): (attach Continuation Sheef(s) 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 ❑ It. in -kind; specify: nature _ ❑ a. deferred value _ ❑ f. other; specify: 14. Brief Description of Services Performed or to be Performed and Dates) 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: ❑ Yes ❑ No 16 Information requested through this form Is eufinc d by title 31 U.S.C. section Signature: g 1352. Thia disclosure of lobbying adivifies is a material representation of fact print Name: upon which raiianoa was placed by the tier above when this transaction was made or entered! into, This diadceure is required pursuant to 31 U.S.C. 1352. This Title: information will be reported b the Congress semi-annually and will be available for public inspection. My person who fell to file the required disdosura shall be Telephone No.: __--- ___ Date: subject to a civil penalty of not less that $10,00D and not more than $100.000 for eachsuch failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)