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<br />"'" <br />Disclosure of Lobbying Activities <br /> <br />"':""::'~!:';':~,-.~...,,~,~~ <br />, ,".' .' .,'f'~ "..........,.'". ...k~1>.._.."...,..,:....~, ", .Jf,...... Jr.". <br />, "", ".>' '~.~' ., ,.,-.... " ,~., -'", " .... ..... -:.... ~'-'~''''', ',"':,' <br /> <br />Appfoved by OMB ~ <br /> <br />Complete this form to disclose lobbying aclivities pursuant to 31 U.S.C. 1352 <br />(See """,,se side fo, InslnJcIions and Public Reporting burden statement) <br /> <br />1. Type of Fede~ction 2. Statu. of Federal Action 3. Ropoft Type <br />o a. contract o a. bid/offer/application o a.lnitial filing <br /> b. grant b.lnillal 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 01 last report ("'!"'dd/YYYY)--- <br />~ N.....nd Addres,'of Reporting Entity 5. If Reporting Entity In No. 4 Is.&Iba'Nardee. enter Name and Address <br />OPrime o Subawardee Tier . if known: of Prime <br />Congressional District. if known Congressional District" if known <br />6. Federal Department/Agency 7. Federal Program NamelDeseripOon <br /> - <br /> CFDA Numbet'. If appfocable <br />8.. Federal Action Number, if known 9. Aw.rd Amoun~ If known <br /> $ <br />10a. Name and Address of lobbying Registrant b. Individuals Pedonning Services ftnducfmg address if different from No. 10a:) <br /> (if individual,lasl name, firsl name. MI) (last name, flf'St name, Ml) <br /> <br />(attach continuation sheet(s) if necessary) <br /> <br />11. Amount 01 Payment (check au _apply) <br />$ - <br /> <br />13. Typeaf"-ant(checkallhatapply) <br />o 8. retainer <br />o b. one-time fee <br />o c. commission <br />D d. contingent fee <br />D e. deferred <br />Of. other(specify) <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 />planned <br /> <br />12. Form of P.yment (check all that apply) <br />o a. cash <br />D b. in-kind; specify: nature <br />value <br /> <br />(attach continuation sheet(sl if necessary) <br />15. Continuation sheets attached 0 Yes D No <br /> <br />16. Information requested through this form is authorized by See.319. <br />Pub. L. 101-121. 103 Stat. 750. as amended by sec. 10; Pub. L. 104- <br />65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />is a material representation of fad 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 U.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 to a civil penalty of not less than $10,000 <br />and not more than $100,000 for each such failure. <br /> <br />Print Name <br /> <br /> <br />,,~~ <br />(~. <br />llt{- - <br /> <br />~ <br />~U~~Y) <br />'U\(~ <br />If~o - 1"'....6" <br /> <br />Signature <br /> <br />11tIe <br /> <br />Telephone No. <br /> <br />Fell~~I-Use~nly:' <br />,." ." <br /> <br /> <br />Authorized for local Reproduction <br />Standard Form.LLL (7/97) <br />