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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 osn~ooas <br />(See reverse for public 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 />^ Prima ^ subawardee and Address of Prime: <br />Tier _____, if known: <br />Con ressional District, if known: Con ressional District, if known: <br />6. Federal DeparfinenUAgency: 7. Federal Program NamelDescription: <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 Performing Services (including address if <br />(if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name, MI): <br />(attach Continuation Shee ts SF-LLLA, i/necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />_ ^ actual ^ Planned ^ a. retainer <br /> ^ b. one-time fee <br />12. Form of Payment (check all that appy): ^ c. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind;. specify: nature ^ e. deferred <br />value ^ f. other; specify: <br />14. Brief Description of Services Pertortned 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) SF-LLLA, i/necessary) <br />15. Continuation Sheets SF-LLLA attached: ^ vas ^ No <br />1t1 Informa0on raWxted Nrwyt Nlc form fs aMOitmtl M Ntle 31 U.S.C. sectlon Signature: <br />135z. Thu tlkaoaae of ioNtlN^N aaniuec is a material .spresenreAOn a rea <br />appn,~d„aea~a.,aawapaa~,mana.a~aa~,n,iao-ansactlpn.asmaae <br />t b 31 U <br />1352 <br />Thi <br />M <br />tl I <br />b <br />Thi <br />tli <br />d <br />i <br />i <br />tl <br />S <br />C Print Name: <br />a er <br />ars <br />n <br />. <br />s <br />a <br />wwe <br />s reyu <br />re <br />pursuan <br />. <br />. <br />. <br />. <br />s <br />iniarmatlon wAl M reported b Na Congress eemi~annualN antl vriA be availabb br <br />T <br />tl <br />pudk nepeabn. My person wino Pals b Ab tM rNryiretl dcdpcure GuN Ee i <br />e: <br />sWjecl b a evil peridN al rot bce Nal 510,000 eM rwt more Nan 5100,000 fur <br />.aa,.ud,rawra. <br />Telephone No.: ______ Date: <br />~p 'y :r:~ i. <br />FedN~ Authorized for Local Reproduction <br />i Standard Fortn LLL (Rev. 7-97) <br />