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....... ..~.. ,... :,' ,-"~'" '-' -' Disclosure of Lobbying Activities Approved by OMB 0348-0046 Complete this form to dlsdose 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 --- I. 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 DSubawardee 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. 103.) (if individual. last name, first name. MI) (last name, first name, MI) $ (attach continuation sheet{s) if necessary) 13. Type 01 Payment (check atl that apply) D a. retainer D b. one~time fee D c. commission D d. contingent fee D e. deferred D f. other (specify) 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 actual planned 11. Amount 01 Payment (check all that apply) 12. Form of Payment (check all that apply) Da Db cash in-kind; specify: nature value 14. (attach continuation Sheet(s) If necessary) 15. Continuation sheets attached D Ves 0 No 16.lnlormation requested through this lorm is authorized by Sec.319, Pub. L. 101.121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- Signature 65, Stat. 700 (31 V.S.C. 1352). This disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 V.S.C. 1352. This inlormation Titte will be reported to the Congress semiannually and will be available for public inspection. Any person who falls to file the required Telephone No. disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Date (mm/ddlyyyy) Federal Use Only: Authorized for local Reproduction Standard Form-LLL (7/97)