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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 0349-0046 (See reverse for Dublic 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: 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, Ml): different from No. 10a) (last name, first name, MI): (attach Continuation Sheets) SF-LLLA, itnecessary) 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), employes(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: ❑ Yea ❑ No 16 Infonnetion'equested through this forth is auNonted by title 31 U.S.C. section Signature: g 1352. This disclosure of lobbying sadvilies Is a material representation of fact upon which reliance was placed by Me tier above when Mis bansaction was made or entered info. This disdo re is required pureuent l0 31 U.S.C. 1352. This print Name: Title: information will be reported to Me Congress semi-annually and will be available for public Inspection. Any person who fails fo file to required disclosure shall be Telephone No.: _--- __— Date: subject to a evil comity of not less Mat $10.000 and not more Man $100,000 for earn such failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)