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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 ❑ 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 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, 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 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 Intonationyu reeated through this form is authorized by We 31 U.S.C. section 16. Signature: 1352. This disdosum of lobbying activities is a material representation of fact print Name: upon which reliance was placed by the ter above when this transaction was made or entered into. This disdosure is required pureuant to 31 U.S.C. 1352. This Title: Information will be reported m the congress semi-annually and will be available for inspection. public My person who fails to file the mound disclosure shall be Telephone No.: Date: subject to a civil penalty of not less that $10.000 and not more Nan $100.000 for aachsuch failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)