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<br />,.... '.~_., K 'K 'KK_' <br /> <br />:""';~~~~tt~~~"'~f <br />Disclosure of Lobbying Activities <br /> <br />'-' <br /> <br />Approved by OMS 0348-{)046 <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br /> <br />1. Type of Federal Action 2, Status of Federal Action 3. Report Type <br /> o a. contract o a. bid/offer/application o a.lnitial filing <br /> b. grant b. innial 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 ("'!"'ddlyyyy)___ <br /> - -, <br />4. Name and Address of Reporting Entity 5. If Reporting Entity In No. .15 Subaward.., enter Name and Address <br /> o Prime D Subawardee Tier , if known: of Prime <br /> Congressional District, if known Congressional District., if known <br />6. Federal DepartmenUAgency 7, Federal Program NamelDescriptlon <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 Performing Services (Including address if different from No. 10a.) <br /> (if individual, last name, first name, Ml) (last name, first name, MI) <br /> <br />11. Amount of Paymant (check all that apply) <br />$ actual <br />12. Form of Payment (check all that apply) <br />D a. cash <br />D b. in-kind; specify: nature <br />value <br /> <br />(attach continuation Sheet{s) if necessary) <br />13. Type of ~ (check all that apply) <br /> <br />D 8. retainer <br /> <br />D b. one-time fee <br /> <br />D c. commission <br /> <br />D d. contingent fee <br /> <br />D e. deferred <br /> <br />o f. other (specify) <br /> <br />planned <br /> <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Servlce,lncluding officer(s}, employee(s), or Member(s) contacted, <br />for Payment Indicated in Item 11 <br /> <br />(attach continuation sheet(s) If necessary) <br /> <br />15. Continuation sheets attached DYes D No <br /> <br />16. Information requested through this form is authorized by 8ec.319, <br />Pub. L 101-121, 103 Stat 750, as amended by sec. 10; Pub. L 104- Signature <br />65, Stat 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />is a material representation of fact upon which reliance was placed Print Name <br />by the above when this transaction was made or entered into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. This Information Tille <br />will be reported to the Congress semiannually and will be available <br />for public inspection. Any person who fails to file the required Telephone No. <br />disclosure shall be subject to a civil penalty of not less than $10.000 <br />and not more than $100,000 for each such failure. <br /> <br />Felleral Use:<>nly: <br /> <br /> <br /> <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />