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'/0" '- Disclosure of Lobbying Activities Complete Ulis fann to disclose lobbying actMUes pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden statement) ApPfOVed by OMB 0348-0046 ' 1. Type of Federal Action 2- Status of Federal Action 3. Report Type 08. contract o a. bid/offer/application o a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only d. loan year (yyyy) quarter ___ e. loan guarantee f. loan insurance date ofla5t report (mm/ddlyyyy)_____ 4. Name and Address ':-of Reporting Entity 5. If Reporting Entity in No.4 Is Subawardee, enter Name and Address o Prime D Subawardee Tier , if known: of Prime Congressional District, if known Congressional District. if known 6. Federal OepartmentJAgency 7. Federal Program NameJDescription _. CFDA Number, if applicable 8. Federal Action Number, if known 9. Award Amount, if known S 10a. Name and Address of Lobbying Registrant b. tndividuals Performing Services (including address ifdifferent from No. tOa.) (if individual, las( name. first name, MI) (last name, first name, Ml) .. $ (attach continuation sheel(s) if necessary) 13. Type of Payment (check all that apply) 11. Amount of Payment (check alllhat apply) actual planned 12. Form of Payment (check all that apply) D a cash D b in-kirld: specify: nature ______________________ .,'3~ue D a. retainer D b. one-time fee D c. commission [~ d. contingent fee o c. deferred LJ f. other (specifyl____________________________________ 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11 (attach continuation sheet(s) if necessary} 15. Continuation sheets attached 0 Yes 0 No 16. Information requested through this form is authorized by Sec.319, Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- 65. Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semiannually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Signature Print Name Title Telephone No. Federal Use Only: Authorized for Local Reproduction Standard Form-LlL (7197) Date (mmlddlyyyy)