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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 Dublic burden disclnsura_1 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing El 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: S. 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, Ml ): (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 Members) contacted, for Payment Indicated in Item 11: (attach Continuation Sheets) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached. ❑ yes ❑ No 16. Information Mm—tB mresah mis yam is aumorlred by We 31 U.S.C. sad IW2. This disdowre d bbbylrg ac sg is a mstedal mpmftM w d fact Signature: g Print Name: upon w rellance w placed by da bar above wtwn mis transaction was maas or adored IMo. This disdo is re Wml Wmusnt l0 31 U.S.C. M2. This Title: Informafion WIa be reported m the Conpnss serx-anrwally and wia be svailaWo M public xupadim. Any person who fails b file me wp;re disdosure shay bs wbject to a da pamally d na lass mat $10. o and nm more man $IN, 00 for Oh BBs' fsure Telephone No.: _ _ Date: bd$fali'tlsA I qny: Authorized for Local Reproduction T, Standard Form LLL (Rev. 7-97)