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<br /> 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 />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a. contract Da. bid/offer/application D 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 />0 Prime 0 Subaward.. and Address of Prime: <br /> Tier --' if known: <br />ConQresslonal District, if known: Congressional District, if known: <br />6. Federal DepartmenttAgency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: ----- <br />8. Federal Action Number, ff 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, M/): different from No. 10a) <br /> (last name, first name, M/): <br /> <br />(attach Conlinualion Shee/(s) SF-LLLA, ¡(necessary) <br />11. Amount of Payment (check aI/ that apply): 13. Type of Payment (check all that apply): <br /> <br />$ ---- 0 actual 0 planned 0 a. retainer <br />0 b. one-time fee <br />0 c. commission <br />0 d. contingent fee <br />0 e. deferred <br />0 f. other: specify: -------- <br /> <br />12. Form of Payment (check all that apply): <br />0 a. cash <br />0 b. irHtind: specify: nature --- <br />value -- <br /> <br />14. Brief Description 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 11: <br /> <br />(attach Conlinualion Shee/(s) SF-LLLA. if necessary) <br />15. Continuation Sheet s SF-LLLA attached: 0 Ves 0 No <br /> <br />16.::-:-:: =..::. ';,....:,::=.:. '::'.::..":. ti:::~~:;: '::;; Signature: <br /> <br />:::.= ::.~:";~-:::.tiy.""':::"":;= ~'3~1;~ m;;:: Print Name: <br /> <br />==..:: ':::;:'::"'wh"::Mk> ':"=~::' :':::"":::::: TItle: <br />...... k> . "". ,,- of 001 .... ~.. $'0.000 ."" 001 ~. ~." $100.000 1", <br />."h"""",,~.. Telephone No.: <br /> <br />Date: <br /> <br /> <br />Authorized for Local Reproduct;on <br />Standa,d Fo>m LLL (Rev. 7-97) <br />