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~""","'","". .,t",t; ""'" ...J Disclosure of Lobbying Activities Approved by OMB 0348-0046 . Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden statement) 1. Type of Federal Action 2. Status of Federal Action 3. Report Type D a. contract D a. bid/offer/application D a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only d. loan year (yyyy) _____ quarter ______ e. loan guarantee f. loan insurance date of last report (mm/dd/yyyy)______ 4. Name and Address 'of Reporting Entity 5. If Reporting Entity in No.4 is Subawardee, enter Name and Address DPrime D Subawardee Tier ___ ,if known: of Prime 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 $ 10a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from No.1 Oa.) (if individual, last name, first name, Ml) (last name, first name, MI) (attach continuation sheet(s) If necessary) 11. Amount of Payment (check all that apply) $ ___ actual planned 13. Type of Payment (check all that apply) D 3. retainer D b. one-time fee D c. commission D d. contingent fee D e. deferred D 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 12. Form of Payment (check all that apply) Da Db cash in-kind; specify: nature value (attach continuation sheel(s) jf necessary) 15. Continuation sheets attached DYes D No 16. Information requested through this form is authorized by Sec.319, Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- 65, Stat. 700 (31 U.S.C.1352). This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 V.S.C. 1352. This information will be reported to the Congress semiannually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penaity of not less than $10,000 and not more than $100,000 for each such failure. Signature Print Name Title Telephone No. Federal Use Only: Date (mm/dd/yyyy) Authorized for Local Reproduction Standard Form-LLL (7/97)