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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 034"046 (See reverse for Dublic 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 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 DepartmentlAgency: 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, 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), 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 16. nformation requested Nrough this form is wNUUed by title 3t U.S.C. section 1352. This disclosure of lobbyirp sound. is a material representation of teR Signature: g Print Name: upon wTkh reliance was placed by the tier above when tics bensasTon was mass or entered into. This disdos ne is requlreE len ant te 31 U.S.C. IM2, This Title: information via be reported to the Congress ssml-annually and will be aveilsbb for publk inspecdon. My person who his to file the required disclosure shall be Telephone No.: Date: subject to a civil penalty of not Were that fio,OW and not mMan an f1W.M for each aaM faYare. S Federal Ott)y: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)