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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: Con ressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: 8. Federal Action Number, ffknown: 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 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 16 Information requested through this form is suModzed by title 31 U.S.C. section Signature: 1352. This disclosure of lobbying activities is a materiel representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is requirel pursuant to 31 U.S.C. 1352. This print Name: Title: information will he reported to the Congress semi-annually and will be available for public inspection. Any person who fails b file the required disclosure shall be Telephone No.: Date: subject to e dvil penalty of not Was that $10,000 and not mora than $100,000 for each such failure. Federal Use Only:, Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)