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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 034e-0046 (See reverse for Dublic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract El a. bid/offer/application 171 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, 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 Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16 Infprmetion requested through Nis form is aWhodzed by tide 31 U.S.C. section Signature: 1352. This disdowns of lobbylrg activities is a material representation of fast Print Name: upon whkh radiance was placed by Me tier above when this transaction was made pr entered info. This disclosure is required pursuant to 31 U.S.C. 1352. This Title: information wa be repoded to the Continue seml-annually and MU be available for publk espedlon. My person who fails b as the required diad0suia shall be Telephone No.: Date: subled b a civil panaay of raA less Nat $10,000 and not more than $100,000 for each suds failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)