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^.," ....,.^_i.....,....";,,.~.~_:. ...._......_,.~ '-' -....I 1. Type of Federal Action: D a. contract b. grant c. cooperative agreement d. loan e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: o Prime 0 Subawardee Tier ____, if known: DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 See reverse for ublic burden disclosure. 2. Status of Federal Action: 3. Report Type: Da. bidioffer/application D a. initial filing b. initial award b. materiai change c. post-award For Material Change Only: year __ quarter date of last report Approved by OMS 0348-0046 5. If Reporting Entity in No.4 is a Subawardee, Enter Name and Address of Prime: Con ressional District, if known: 6. Federal Department/Agency: Con ressional District, if known: 7. Federal Program Name/Description: CFDA Number, if applicab/e: 8. Federal Action Number, if known: 10. a. Name and Address of Lobbying Entity (ifindividual, last name, first name, MI): 9. Award Amount, if known: $ b. Individuals Performing Services (Including address If different from No. 1 Oa) (last name, first name, MI): (attach ConUnuaUon Sheet(s) SF-LLLA, Ilnece j 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ _____ D aclual D planned D a. retainer o b. one-time fee D c. commission o d. contingent fee D e. deferred D f. other: specify: 12. Form of Payment (check all that apply): D a. cash o b. in-kind; specify: nature ___ value ___ 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: (aUacIJ ContinuaUon Sheet(s) SF-LLLA, II necessa j 15. Continuation Sheet s SF-LLLA attached: D Y.. D No 16 InronnaUon requested through this form Is authorized by Utle 31 U.S.C. section Signature: . \352. This dIsc:Iosure of lobbying activilllls Is a malarlel reprell8ntalion of rae( uponwhic;hrelillncewuplaceclbylhelierabovewhenlhillrensactionwalmld. P' t N or entered into. This disdosulll Is required pursuant 10 31 U.s.C. 1352. This nn sme: InformaUcn wll be IlIported to the Congess seml-annualy end wDl be eveUable for Title'. pubic lnspectlcn. Any person who falls to ilIa the reqUi'ed discto8U,. Ihall be subJllICl: to a civil penalty of not lass thai $10,000 and not mora then $100.000 for aac;hsudlfaIIuAl. Telephone No.: Fe.deral UseClnly: Date: Authorized for Local Reproduction Standard Fonn LLL (Rev. 7-97)