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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 oublic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract El a. bid/offer/application Ej 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, MI): different from No. 10a ) ( last name, first name, MI): (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 ❑ It. 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 Sheets) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No Information repuestetl through this form is auhoriaed by title 31 U.S.C. section 16. Signature: 1352. This disdosure of lobbying activities is a material representation of fad Print Name: upon which reliance was placed by the bar above when his transaction was mantle or entered into. This died.. a is required pursuant to 31 UScC IM2. This Title: infomation will be reported to the Congress semi-annually and will be available for public inspection. Any person who fails to file her required disclosure shall be Telephone NO.: Date: subject to a civil penalty of not less that E10,00g and not more than $10g000 for each such failure. Federal Use Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)