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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 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 I. 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, MI): different from No. 10a) (last name, first name, Ml): (attach Continuation She 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 16 Information recuested through this form u authorized by tige 31 U.S.C. sea. Signature: 1352. This disclosure of lobbying activities is a matenal representation of fact print Name: upon which reliance was placed by the tier above when this bamadlon was made or entered into This disdovure is requbed pursuant to 31 U.S.C. 1352. This Title: information wiM be reported b the Congress aemiannually and will be avatiable for pudic inspection. My person who fails to She the required disclosure shall be Telephone No.: Date: subject to a civil penafy of not less that =11),00) and not more then $IW, H1 for each such failure Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7 -97)