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-.-..... t '-' '-' Disclosure of Lobbying Activities Approved by OMB 0348-0046 Complete this form to disdose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden slalement) 1. Type of Federal Action 2. Status of Federal Action 3. Report Type D a. 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 of lasl report (mm/ddJyyyy)_____ 4. Name and Address10t Reporting Entity 5. It Reporting Entity in No.4 is Subawardee, enter Name and Address DPrime D Subawardee Tier , if known: of Prime Congressional District, if known Congressional 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 $ 10a. Name and Address of Lobbying Registrant b. Individuals Perfonning Services (including address If cfrtferent from NO.1 Oa.) (if individual. last name, first name, MI) ~ast name, first name, MI) . . (attach continuation sheet(s) If necessary) 11. Amount of Payment (check all that apply) $ acllJal planned 12. 13. Type of Payment (check all that apply) D a. retainer o b. one-time fee D c. commission D d. contingent fee D e. deferred D f. other (specify) 14. Brief Description of Services Performed or to be Perfonned and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11 Form of Payment (check all that apply) D a. cash o b. in.klnd; specify: nature value (attach continuation sheet(s) if necessary) 15. Continuation sheets attached DYes D No 16. Information requested through this form is authorized by 8ec.319, Pub. L. 101.121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- Signalure 65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name by the above when this transaction was made or entered into. This disclosure Is required pursuant to 31 U.S.C. 1352. This information Tille will be reported to the Congress semiannually and will be available for public inspection. Any person who fails to file the required Telephone No. disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure~. Date (mm/ddlyyyy) Federal Use Only: Authorized for Local Reproduction Standard Fonn-LLL (7/97)