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<br />'-' <br /> <br />....I <br /> <br /> See reverse for oublic burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a. contract Da. 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 ________ quarter ________ <br />e. loan guarantee date of last report _____________ <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br />o Prime D Subawardee and Address of Prime: <br />Tier ~----, if known: <br />Conaressional District. if known: Congressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, If applicable: ____________ <br />8. Federal Action Number, if known: 9. Award Amount, If known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): different from No. 10a) <br /> (last name, first name. MI): <br /> (attach Continuation Sheet(s) SF-LLLA, if necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ---------- o actual o planned o a. retainer <br /> o b. one-time fee <br />12. Form of Payment (check all that apply): o c. commission <br />o a. cash o d. contingent fee <br />o b. in-kind; specify: nature ------- o e. deferred <br /> value ---------- o f. other; specify: ______________ <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br /> (attach Continuation Sheet(s) SF~LLLA, if necessary) <br />15. Continuation Sheet(s) SF-LLLA attached: DYe. DNa <br />16 Information requested through this form, is authorized by title 51 U.S.C. section Signature: <br />. 1352. Thl$ disdosure of lobbying activitieS 1$ a matenal repre5EIntatlon of fad: <br />upon which reliance was placed by the tier above when this transaction was made Print Name: <br />or entered into. This disdosure is required pursuant to 31 U.S.C. 1352. This <br />informatioo will be reported to the Con!1ess semi-annualy and will be available for Title: <br />public inspectioo. Any person who fails to file the required disdosure shall be <br />subjeclto a civil penalty of no I less lhat $10,000 and not more than $10 0,000 for Telephone No.: Date: <br />each sudl failure. <br />Federal Use Only: I Authorized for Local Reproduction <br /> Standard Form LLL (Rev. 7-97) <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMS <br />0348-0046 <br />