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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 0348-0046 <br />See reverse for public burden disclosure.) <br /> <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />contract <br /> a. bid/offer/application ~ a. initial filing <br /> ~ ~b. initial award~ "'~ b. material change <br /> ~ ' b. grant <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 />[] Prime [] Subawardee and Address of Prime: <br />Tier __, ifknown: <br />Congressional District, ifknown: Congressional District, ifknown: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: _ __ <br />$. Federal Action Number, if known: 9. Award Amount, if known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): different from No. l Oa ) <br />(last name, first name, MI): <br />(attach Continuation Shee~$) SF-LLLA, if necessaq/) <br /> 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br /> $ [] actual [] planned [] a. retainer <br /> [] b. one-time fee <br /> 12. Form of Payment (check all that apply): [] c. commission <br /> [] a. cash [] d. contingent fee <br /> [] b. in-kind; specify: nature _.__ [] e. deferred <br /> value [] f. othen specify: <br /> <br /> t4. Brief Descflption of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br /> employee(s), or Member(s) contacted, for Payment Indicated In Item ¶ 1: <br /> (attach Congnua~lon Sheet(e) SF. LLLA, ff necsssaq/) <br /> t5. Continuation Sheet(s) SF-LLLA attached: [] Yes [] No <br /> 16 Infom~alion r~ted Ihmugh ~ls f~/111~ autho~zed by ~JUe 31U.~.C. ~iofl Signature: <br /> -~, -~ f,~.. Telephone No.: Date: <br /> Standard Form LLL (Rev. 7-97) <br /> <br /> <br />