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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 1-7 El 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, 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 ❑ I. 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. lnfornetie" resuesle t thmagh this form is auhodmd by title 31 U.S.C. section Signature: 1352. This dhwlm na of lobbying activities is a material representation of fact Print Name: upon which reliance was placed by the tar above when this transaction was made a entered info. This disdosure is repuNed pursuant a 31 U.S.C. 1352. This Title: intonation will be reported to he Congress semi-annualy and will be available for pubic hspection. Any person who falls to file the re,,uha i diadosure shell be Telephone No.: _--- _ Date: subject to a civil penalty of not less that $10,000 and not mae than S100,000 for each sudh failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)