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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 0348-0046 (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract �a. bidloffer/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 I. 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, if known: 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, MI): different from No. 10a) (last name, first name, MI): (attach Continuation Sheet(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 ❑ 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), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheets) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ yes ❑ No 16Information requested through Nis form b authodred by title 31 U.S.C. section . Signature: 1352. TNs disdoa re of lobbying activi es is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered mlo. This disdiosure is required pursuant to 31 U.S.C. 1352. re, Print Name: Title: infometion will be reppded to the Congress semFannualy and will be available for public inspection. My parson who fails to file the requiretl disclosure shall be Telephone No.: __------- Date: subject to a civil penally of not less that $tg," and not more than ftgg.flge for each audit failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)