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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-oons- <br />(See reverse for public burden disclosure.l <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 ,ifknown: <br />Con ressional District, ifknown: Con ressional District, ifknown: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: ____ <br />8. Federal Action Number, ifknown: 9. Award Amount, ifknown: <br /> <br />10. a. Name and Address of Lobbying Entity b. Individuals Pertorming Services (incuding address if <br />(if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name, Ml): <br />(attach Continuation Shee t(s) SF-LLLA, i/necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that appy): <br />^ actual ^ planned ^ a. retainer <br /> ^ b. one-flme fae <br />12. Form of Payment (check all that apply): ^ e. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind; specify: nature ^ e. defened <br />value _ ^ f. other, specify: ___ _ <br />14. Brief Description of Services Pertormed or to be Pertormed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br />(attadr Continuaton Sheet(s) SFLLLA, ifnecessary) <br />15. Continuation Sheets SF-LLLA attached: ^ vas ^ No <br />1 tl. Information reVaestea Mmupn Ws form is auMO,rzea try tltle 31 ta.3.C, section <br />Si <br />nature <br />1353. Tnie disdosuro of lcEbyi^a ectlviUes {s a material reprecanb5on o1 ixt g <br />: <br />awn wtapn reliance was placed er Me tler above when Mie veneac0on was made <br />« snbretl imp. This disdoe«e is mQUire0 pursueM m 31 U.S.C. 13sz. mis Print Name: <br />imormalipn win be rep«lea ro Me Con9reu semi-annualH and wui i» avaaawe ro. <br />w,am U,epection. nny perwn Wnp rase m ae the mamrea aeaoeare v,aa ne <br />Title: <br />subject m e civil penalty of not bas Met 510,000 ens rwt more Men 5100,000 for <br />.apn east raaare. Telephone No.:__ _____ Date: <br /> <br /> <br />•y C. <br />}}~~~~. <br />~kClOra).t)' ~~ d `~ w AuNOrized for Local Reproduction <br /> <br /> <br />~° <br />:: , . .. ; ; <br />; Standard Fonn LLL (Rev. 7-97) <br />