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<br />Disclosure of Lobbying Activities Approved by OMB 0348-0046 .
<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 /> D a. contract D a. bid/offer/application o a. 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 (mmldd/yyyy)_____
<br />4. Name and Address 'of Reporting Entity 5. If Reporting Entity in No.4 is Subawardee, enter Name and Address
<br /> DPrime D Subawardee Tier __ I 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. Namt: and Address of Lobbying Registrant b. Individuals Perfonning Services (including address if different from No. 10a.)
<br /> (if individual, last name, first name, Ml) (last name, first name, Ml)
<br />
<br />12. Form of Payment (check all that apply)
<br />
<br />(attach continuation sheet(s) if necessary)
<br />13. Type of Payment (check all that apply)
<br />o 8. retainer
<br />
<br />D b. one.time fee
<br />o c. commission
<br />
<br />o d. contingent fee
<br />
<br />o e. deferred
<br />
<br />o f. other (specify)____________________~__
<br />
<br />14. Brief Description of Services Periormed or to be Periormed and Date(s) of Service, including officer(s}, employee(s), or Member(s) contacted,
<br />for Payment Indicated in Item 11
<br />
<br />$
<br />
<br />actual
<br />
<br />planned
<br />
<br />11. Amount of Payment (check all that apply)
<br />
<br />Da
<br />Db
<br />
<br />cash
<br />
<br />in-kind; specify: nature
<br />
<br />value
<br />
<br />(attach continuation sheel(s) if necessary)
<br />15. Continuation sheets attached DYes 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 disclosure of lobbying 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 />Signature
<br />
<br />Print Name
<br />
<br />Title
<br />
<br />Telephone No.
<br />
<br />Oete (mmlddlyyyy)
<br />
<br />Authorized for Local Reproduction
<br />Standard Form-LLL (7/97)
<br />
<br />Federal Use Only:
<br />
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