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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 03411-0046 <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 />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 />6. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />❑ Prime ❑ Subawardee <br />and Address of Prime: <br />Tier--, 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 />S. 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 <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 Sheets) SF-LLLA, if necessary) <br />15. Continuation Sheets SF-LLLA attached: ❑ yes ❑ No <br />16 Mfis sss n requested th o h Mi. f : aulhorized by we 31 U.S.C..etk <br />1352. This dktoens of kbbpW ss villes is a material retpresenlstim a fa <br />Signature: <br />g <br />Print Name: <br />upon w reliance wet pkced by Me tier above when Mis transaction was made <br />w entered Imo. TM. Osclowre is raqu4etl pursuant k 31 U.S.C. 1352. niis <br />Title: <br />information wir be reported k Me Coe,.. semi-annually end wir be evsilsb roil <br />M&k inspection. My person who fails k fie Me required disclosure shall be <br />Telephone No.: Date: <br />subist We tvr penalty of rwt Ise. Mel s10.oxI entl rwt more Man s1m," roil <br />eat, .at, fes.. <br />Authorized for Local Reproduction <br />standard Form LLL (Rev. 7-97) <br />