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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 0348-0e46 (See reverse for public 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 ❑ 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, /fknown: 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), employes(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLIA attached: ❑ Yes ❑ No 16. Infonneke, requested through section ugh thus form is mlhodby Oft 31 U.S.C, 1352. This disdosum of tobbyirp ectMtlss is a material reDresemation of hct Signature: upon which reliance was paced by Me tier above when Nis Vansadlon was made or embmd into. This disclosure is mquhed Wrsuam b 31 U.S.C. 1352. This print Name: Title: Infatuation will be reported to Me Congress semi-annually and wig be available M public inspection. My person who fags to file Me requimd disdosure shall lea Telephone No.: Date: subject to a p O penalty of not tots that$10.000 and no more Man $100,000 for each surlh failura. I � Authorized for Local Reproduction ' • Standard Form LLL (Rev. 7-97)