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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 0348-0o46 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: i. 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, MI): (attach Continuation Sheet(s) SF-LLLA, if necessary) 11. Amount of Payment (check all that apply): t3. Type of Payment ( check all that apply): $ [] actual [] planned [] a. r~tainer [] b, one-time fee 12. Form of Payment (check all that apply): [] c. commission [] 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 Sheet(s) SF-LLLA attached: [] Yes [] No 16 Information requested thrcugh this form is autho~zed by m*6e 31 U.S.C. section Signature: · 1352. 9~nie disclosure of ~obbying acfiv~Jes is s materia~ representation of fact upon which reliance w~ms placed by the tier above when this transaction was made o? ante?ed in~o. This d~c{osure is ~equired pursuant ~o 31 U.S.C. 1352. This Print Name: infornlaflon will be rep~ ~o the congress semi-annually and will be available fc~ public inspection+ Any person who fails to 19la the required disclosure shall be Title: subject to a civil penalty of not less that $10,000 and not more than $100,000 fo~ each such failure. Telephone No.: Date: ;Federal use Only: Authorized for Local Reproduction Standard Form LLL (Rev, 7-97)