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<br />
<br />
<br />Disclosure of Lobbying Activities Approved by OMB 0346-0046 .
<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 D 8. 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 (yyyy) ___ quarter ____
<br /> e. loan guarantee
<br /> f. loan insurance date of last report (mmfdd/yyyy)_____
<br />4. Name and Address Tof Reporting Entity 5. If Reporting Entity in No.4 is Subawardee, enter Name and Address
<br />DPrime D Subawardee Tier , if known: of Prime
<br />Congressional District, if known Congressional District, if known
<br />6. Federal Department/Agency 7. Federal Program Name/Description
<br /> ..
<br /> CFDA Number, if applicable
<br />8. Federal Action Number, if known 9. Award Amount, if known
<br /> $
<br />10a. Nam~ and Address of Lobbying Registrant b. Individuals Performing Services (iocluding address if different from No. 103.)
<br /> (if individual, last name, first name, MI) (last name, first name, MI)
<br /> ..
<br />
<br />$
<br />
<br />actual
<br />
<br />(attach contmuatlon sheet(s) if necessary)
<br />13. Type of Payment (check all that apply)
<br />
<br />D a. retainer
<br />
<br />o b. one-time fee
<br />
<br />o c. commission
<br />
<br />D d. contingent fee
<br />
<br />D e. deferred
<br />
<br />D f. other (specifYL______________________.__________
<br />
<br />planned
<br />
<br />11. Amount of Payment (check all that apply)
<br />
<br />12. Form of Payment (check all that apply)
<br />
<br />Oa
<br />Db
<br />
<br />cash
<br />
<br />in-kind; specify: nature
<br />value
<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 />(attach continuation sheel{s) if 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-
<br />65, Stat. 700 (31 U.S.C. 1352). This disciosure ofiobbying activities
<br />is a material representation of fact 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 />Federal Use Only:
<br />
<br />Signature
<br />
<br />Print Name
<br />
<br />Title
<br />
<br />Telephone No.
<br />
<br />Date (mmldd/yyyy)
<br />
<br />Authorized for Local Reproduction
<br />Standard Form-LLL (7197)
<br />
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