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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 o3ae-Doss <br />See reverse for ublic burden disclosure. <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />a. contract ~a. bid/offer/application ~ a. initial filing <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-award For Material Change Only: <br />d. loan year quarter _ <br />e. loan guarantee date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />^ prime ^ sabavnrdee and Address of Prime: <br />Tier __ if known: <br />Con ressional District, if known: Con ressional District, if known: <br />6. Federal DepartmenUAgency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> <br />10. a. Name and Address of Lobbying Entity b. Individuals Pertorming Services (including address if <br />(if individual, last name, first name, Ml): different from No. l0a) <br /> (last name, first name, MI ): <br />(attach Conanuaton Shee t(sJ SF{LLq, rynecessa <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that appy): <br />- ^ actual ^ pWnned ^ a. retainer <br /> ^ b. onalime fee <br />12. Forth of Payment (check all that apply): ^ c. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind; spectty: nature _ ^ e. deferred <br />V81Ue ^ f. other; specify: _ <br />14. Brief Description of Services Pertormed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) SFLLLA, irnecessary) <br />15. Continuation Sheets SF-LLLA attached: ^ vea ^ do <br />15.Infametion requestetl Mrouph tine farm is eutllotlzetl by titre 31 U.S.C. section <br />Si <br />nature: <br />1352. This tlisdmure of IobbYinB actlvities Ia a mabrial representation of fact g <br />upon which relierke was ptacetl by Me tier above when Nis transaction wm matle <br />a entaretl info. This tlisdosure is ~eauhatl pursuant b 31 U.S.C. 1352. this <br />Print Name: <br />reformation wiN be reportetl ta Ow Canarses aemFamualy entl will be avaseble for <br />piAtic incpaction. Nry person who fails b flla 0w royuirstl dsGOSUn shop be <br />Title: <br />subpct trr a dvY panely of rpt tass NN 510.000 aM red more tlun 5100,000 for <br />eaph epM hilpre. <br />Telephone No.: _____ ___ Date: <br /> <br />~ <br />'~etieraf i~~g )}r <br />AuNorized for Local Reproduction <br /> Stantlard Form LLL (Rev. 7-97) <br />