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...,,/. ~.......... '- ~ 1. Type of Federal Action: o a. contract b. grant c. cooperative agreement d.loan e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: D Prime D 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: Oa. bid/offer/application 0 a. initial filing b. initial award b. material change c. post-award For Material Change Only: year quarter _________ date of last report Approved by OMB 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 applicable: 8. Federal Action Number, if known: 10. a. Name and Address of Lobbying Entity (if individual. last name, first name, M/): 9. Award Amount, if known: $ b. Individuals Performing Services (including address if different from No. 1 Oa) (last name, first name, MI): attach Continuation Shest(s SF..f.LLA, If necessa 1 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ D actual o planned o B. retainer o b. one-tIme fee o c. commIssion D d. contingent fee o e. deferred D f. other, specify: 12. Form of Payment (check all that apply): D a. cash D 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: (attach ConUnuaUon Sheet sJ SF-LLLA, If necassa ) 15. Continuation Sheet s SF-LLLA attached: 0 Yes 0 No 16 Infomlallon requel5Led through thi1l form is aulhorlzecl by IIDe 31 U.s.C. section Signature: . 1352. This disdosure of klbbjlng actMUea Is a malarial repraaen\.ation of (act upon which reIiMice was placed by the lier abcwa w1wn thIa transac:tlon waa mad. P' t N or .nterec:llnto. thIs disdOllUf8 115 requlred puquant to 31 U.s.c. 1352. This nn ama: Informallen wll be reportecIlo the Cong1lU semhlnnualy and wID be avallable for pubic lnspectlcn. My penon whO falls to ftle the required cIIsdosure snail bt subject to . dvll penaUy of not tess thai $10.000 and not mora than $100.000 for eachlUmfllllure. Fed"ra.ll}s!l "nly: Title: Telephone No.: Date: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)