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<br />DISCLOSURE OF LOBBYING ACTIVITIES <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for public burden disclosure.) <br /> <br />Approved by OMB <br />0348-0046 <br /> <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />0 a. contract 0 a. bid/offer/application 0 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 and Address <br />0 Prime 0 Subawardee of Prime: <br /> Tier -' if known: <br />Congressional District. if known: Congressional District. if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicable: <br /> .. <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> $ <br />10. a. Name and Address of Lobbying b. Individuals Performing Services ( including address <br /> Entity if different from No. lOa) <br /> ( ff individual, last name, first name, MI): (last name, first name. MI): <br /> (attach Continuation Sheet(s) SF-LLLA, ff necessary) <br />11. Amount of Payment ( check all that apply): 13. Type of Payment (check all that appiy): <br />$ 0 actual 0 planned 0 a. retainer <br /> 0 b. one.time fee <br /> 0 c. commission <br />12. Form of Payment ( check all that apply): 0 d. contingent fee <br /> 0 a. cash 0 e. deferred <br /> 0 b. in-kind; specify: nature 0 f. other; specify: <br /> value <br /> <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, Including <br /> officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br /> (attach Continuation Sheet(s) SF-LLLA, if necessary) <br />15. Continuation Sheet(s) SF-LLLA attached: 0 Yes 0 No <br />16. Signature: <br />Information requested through this form is authorized by titie 31 Print Name: <br />U.S.C. section Titie: <br />1352. This disclosure of lobbying activities is a material Telephone No.: Date: <br />representation of fact <br />upon which reliance was placed by the tier above when this <br />transaction was made <br />or entered into. This disclosure is required pursuant to 31 U.S.C. <br />1352. This <br />information will be reported to the Congress semi-annually and <br />will be available for <br />public inspection. Any person who fails to file the required <br />disclosure shall be <br />subject to a civil penalty of not less that $10,000 and not more <br />than $100.000 for <br />each such failure. <br /> <br />10 <br />