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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 osas-ooas <br />(See reverse for oublic burden disclosure.l <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />a. contract ~a. bid/offer/application ~ a. initial filing <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-award For Material Change Only: <br />d. loan year ___ quarter <br />e. loan guarantee date of last report _ ___ <br />f. loan insurance <br />4. Name and Address of Reporting Entity: S. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />^ Prime ^ subawardee and Address of Prime: <br />Tier___, ifknown: <br />Con ressional District, ifknown: Con ressional District, ifknown: <br />6. Federal Department/Agency: 7. Federal Program NamelDescription: <br /> CFDA Number, ifapplicable: __ <br />8. Federal Action Number, ifknown: 9. Award Amount, ifknown: <br /> <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name, MI ): <br />(attach Continuatlon Shee t sJ SF-LLLA, i/necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />_ ^ actual ^ planned ^ a. retainer <br /> ^ b. one-time fee <br />12. Form of Payment (check all that appy): ^ o. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind; speciry: nature _ ^ e. deterred <br />value ___ ^ t. other; speciry: <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 Cono'nuation Sheet(s) SF-LLLA, rf necessary) <br />15. Continuation Sheets SF-LLLA attached: ^ vas ^ No <br />1 t) Inbrme0on requested Mrough tks form is auNOdzetl by dga 31 U.S.C. sec9pn Si <br />nature: <br />1352. TNS disGOwre of lobbying activities is a material representaEpn of faG g <br />upon whiGl reliance was pWCed by Me tier above when this trensec9an was matle <br />« entered into. This dudosure is requked pursuant to 31 U.S.C. 1352. This <br />Print Name: <br />infomuGOn will be reported a Me C«gresa sem4annuely and will ba available for <br />Oublic inspection. any parson who fa0s b file the raquiretl disGOSUre ahaY ba <br />Tltle: <br />subject to a Gvil penely of rwt less Mat $10,909 and not m«e Man $199,000 f« <br />aaG, each failure. <br />Telephone No.: ___ ____ Date: <br />Federal Ilse Onlp: Authorized for Local Reproduction <br /> Standard Form LLL (Rev. 7-97) <br />