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"-' ...., DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMS 0346-0046 'See reverse for oubiic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D a. contract Da. 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 _______ 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 o Prime D Subawardee and Address of Prime: Tier ---~~, if known: Conaressional District, if known: Congressional District, if known: 6, Federal DepartmenUAgency: 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, M/): differentfrom No. 1Oa) (last name, first name, M/): (attach Continuation Sheet(s) SF-LLLA, if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ----- o actual o planned D a. retainer o b. one~time fee 12. Form of Payment (check all that apply): o c. commission o a. cash o d. contingent fee o b. in-kind; specify: nature -------~ o e. deferred value --------- Of. 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 Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheetfs1 SF.LLLA attached: DYe. ONo 16 Information requested through this fOllTl is authorized by title 31 U.S:C. section Signature: . 1352. This disdosure of lobbying activllJeS 15 a material representation of facl. upon which reliance was placed by the tier above when this transaction was made Print Name: or entered into. This disdosufe is required pursuant to 31 U.S.C. 1352. This informaticr1 will be reported to the Congress semi-annualy and will be allaUable for Title: pubic lnspeclkn. Any person who fails to file the required disdosunl shall be subjeclta a clllil penalty af not less that S10,OOO and nolmare lhanS100,OOOfaf Telephone No.: Date: eachsudlfailura. Federal Use Only: I Authorized for Local Reproduction Standard Fonn LLL (Rev. 7-97)