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\w '-' DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMS 0348-0046 'See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: o a. contract Oa. 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 quarter ____ e. loan guarantee date of last report f. ioan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity In No.4 is a Subawardee. Enter Name o Prime o Subawardee and Address of Prime: Tier _____. Ifknown: Conaresslonal District, If known: Conaressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: _____ 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (inc/uding address if (if individual, last name, first name, M/): different from No. 1 Oa) (last name, first name, M/): (aUach ContinuatiOll S_tls) SF-LLLA. ir necessarY) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ----- o aclual o planned o 8. retainer o b. one-time lee 12. Form of Payment (check all that apply): o c. commission o a. cash o d. contingent lee o b. in-kind; specify: nature ____ o e. deferred value o f. other, specify: 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: (aUsch Continuation Sheet(s) SF-LLLA, i'necessary) 15. Continuation Sheet/s) SF.LLLA attached: DYe. nNo 16 Information requesl&d through this form II authorized by till. 31 U.S.C. Action Signature: . 1352. This discklllUrB of lobbying acI/vKiaB II a material repr..ntaUon of fact upon which n~llance was placed by the tier abovelllh.n this tran.action was made Print Name: or entered Into. This dlsdl)lUrB Is required pursuant to 31 U.s.C. 1352. This Informatloo will ba reported 10 the Congess IHImi-annualV and will be avallabte for Title: pubic Inlpectlal. Any person who faU, 10 lie &he required d1sdoauN Ihal be wbject to a ciVIl penally of not less that $10,000 and not mort than $100.000 for Telephone No.: Date: aad1sudifal1lr.. . . c" . ...... . ... cc..c. . ... ..:.1 Authorized for Local Reproduction Federal.lJseOnly: .... . .. ..... .. . ... . .... . ... .. . . Standard Form LLL (Rev. 7-97)