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<br />Disclosure of Lobbying Activities
<br />
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<br />
<br />Approved by OMS 0348-ll046 .
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<br />Complete this fonn to dlscloselobbylng octivilios pursuant to 31 U.S.C. 1352
<br />(See reverse side for InstnJctions and Public Reporting burden statement)
<br />
<br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type
<br /> o a. contract D o. 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 (yyyy) quarter
<br /> e. loan guarantee
<br /> f. loan insurance date of last report (mm/dd/yyyy)_____
<br />4. Name and Address "'ot Reporting Entity 5. If Reporting Entity In No. 41s Subawardee, enter Name and Address
<br /> DPrime D Subawardee Tier , if known: of Prime
<br /> Congressional District, if known Congressional District, if known
<br />6. Federal Department/Agency 7. Federal Program Name/Description
<br /> ..
<br /> CFDA Number, if applicable
<br />8. Federal Action Number, if known 9. Award Amount, if known
<br /> $
<br />10a. Name and Address of Lobbying Registrant b. Individuals Pel10rming Services (including address if different from No. lOa.)
<br /> (if individual, last name, first name, MI) (last name, first name, MI)
<br /> ..
<br />
<br />$
<br />
<br />actual
<br />
<br />(attach contmuatlon sheet(s) if necessary)
<br />13. Type of Payment (check all that apply)
<br />
<br />o 8. retainer
<br />
<br />o b. one.time fee
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<br />o c. commission
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<br />D d. contingent fee
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<br />D e. deferred
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<br />D f. other (specifyL______________________________
<br />
<br />planned
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<br />11. Amount of Payment (check all that apply)
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<br />12. Form of Payment (check all that apply)
<br />o a. cash
<br />D b. in-kind: specify: nature
<br />value
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<br />14. Brief Description of Services Pel10rmed or to be Performed and Date(s) of Service, including officer(s}, employee(s), or Member{s) contacted,
<br />for Payment Indicated in Item 11
<br />
<br />15. Continuation sheets attached 0 Yes D No
<br />
<br />16. Information requested through this form is authorized by Sec.319.
<br />Pub. L.101.121, 103 Stat. 750, as amended by sec. 10; Pub. L.104.
<br />65, Stat 700 (31 V.S.C. 1352). This disclosure of lobbying activities
<br />is a material representation of fact upon which reliance was placed
<br />by the above when this transaction was made or entered into. This
<br />disclosure Is required pursuant to 31 V.S.C. 1352. This information
<br />will be reported to the Congress semiannually and will be available
<br />for public inspection. Any person who fails to file the required
<br />disclosure shall be subject 10 a civil penally of not less than $10,000
<br />and not more than $100,000 for each such failure.
<br />
<br />Federal Use Only:
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<br />Signature
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<br />Print Name S.::-( ,,\~... I Go.,l /--- c ~
<br />Title (' L.";,1 ?I! _c~
<br />
<br />Telephone No.
<br />
<br />
<br />(attach continuation sheet(s) if necessary)
<br />
<br />Date (mm/dd/yyyy)
<br />
<br />Authorized for Local Reproduction
<br />Standard Form-lLL (7/97)
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