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<br />'-' <br />Disclosure of Lobbying Activities <br /> <br />...,.:,:::&;~'i;?,~ <br /> <br />~ by OMB 034B-0G4B <br /> <br />Complete this form to disclose lobbying activities ptnUant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Pu~ic Reporting burden statement) <br /> <br />1. Type of Fede......ction 2. Status of Federal ActIon 3. Report Type <br /> 08. contract o a. bid/offer/application o a.lnitial filing <br /> b. grant b.lnitial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Only <br /> d. loan <br /> e. loan guarantee year (yyyy) quarter __ <br /> l. loan insurance date of last report (",!",ddlmYl___ <br />4. Name IIRd Adilre.~'of Reporting Entity 5. If Reporting Entity In No. 4 "'~uba_... enter Name and Addre.. <br /> OPrime 0 Subawardee T"'r . if known: of Prime <br /> Congressional District. if known Congressional Distrid. if known <br />6. FederalDepa~enUAgency 7. Federal Program NamelDescrlptlon <br /> - <br /> CFOA Number.lf__ <br />8. Fed... ActIon Number, if known 9. Award Amount, if known <br /> $ <br />10a. Name and Address of Lobbying Registrant b. Individuals Perfonning Services flf'lCluding address If different from No. 10a;) <br /> (if individual, last name, first name, Ml) (last name. firs! name. MI) <br /> <br />(attach continuation sheet(s) if necessary) <br />13. Type af"-l (chechll that apply) <br />Oa.- <br />o 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 />14. Brief Description of Services Performed 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 />11. Amount of Payment (check all that apply) <br />S aclual <br />12. Form of Payment (check aU that apply) <br />o a. cash <br />D b. in-kind; specify: nature <br /> <br />plamed <br /> <br />value <br /> <br />(attach continuation sheet,s) it necessary} <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- Signalure <br />65. Stat. 700 (31 V.S.C. 1352). This disciosure 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 />disciosure 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 />Fede~ llse.!Only:, <br /> <br /> <br /> <br />Date (mmtddIyyyy) <br />\~~'l'~:;~~;.Jt.::!: Authorized for Local Reproduction <br />;:;\.:t1.72::t\ar;}:~~ff~;~,\:;;~ . Standard Fonn-LlL (7197) <br />