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<br />'- 'oJ <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 OMB <br />0348-004S <br /> <br /> See reverse for public burden disclosure.' <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a. contract Da. bidlofferlapplication 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 o Subawardee and Address of Prime: <br />Tier ___, if known: <br />Congressional District, if known: Conoressional 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. toa) <br /> (last name, first name, M/): <br /> (attach Continuation Sheet(s) SF-LLLA. ifnecessary) <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 D d. contingent fee <br />o b. in-kind; specify: nature ------- o e. deferred <br /> value ------- Of. 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, ifnecessary) <br />15. Continuation Sheetlsl SF.LLLA attached: OVss ONa <br />16 Information requested through this form is ButhoriZed by tide 31 U.S.C. section Signature: <br />"352. This disdosure of Iobtrying activities is a material repreSllntation of fact <br />upon which reliance was placed by the tier above when this transaction was made Print Name: <br />or enlered into. This disdosure is required pursuant to 31 U.S.C. 1352. This <br />informatioo will be reported to the Congess semi.annualy and will be available tor Title: <br />pub~e inspeetioo. My person who fails to lile the required disdosute shall be <br />subject to a civil penalty of not less that $10,000 and nol more than $100,000 for Telephone No.: Date: <br />ead1 suct1 failure. <br />Federal Use Only: I Authorized for Local Reproduction <br /> Standard Form LLL (Rev. 7-97) <br />