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<br />""" <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />-..."I <br /> <br />Approved by OMS <br />0348-0046 <br /> <br /> 'See reverse for Dublic burden disclosure.) <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. ioan year quarter__ <br />e. ioan guarantee date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br />o Prime o Subawardee and Address of Prime: <br />Tier ____, if known: <br />Conaresslonal District, if known: Conaressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, if applicabie: _____ <br />8. Federal Action Number, if known: 9. Award Amount, ifknown: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, M/): different from No. 10a) <br /> (last name, first name, M/): <br /> (attach ContinuaUon Shaet(sJ SF-LLLA, ifnecessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ------ o actual o planned o 8. retainer <br /> o b. one-time fee <br />12. Form of Payment (check all that apply): o c. commission <br />o a. caah o d. contingent fee <br />o b. in-kind; specify: nature ------- o e. deferred <br /> value --- o f. other; apaclfy: <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated In Item 11: <br /> (attach ContinuaUon Shaet(s) SF-LLLA, Ifnecessa~) <br />15. Continuation Sheet/sl SF.LLLA attached: DYes ONo <br />16 Information !'eqlJ8sled through this form Is authorized by!iUe 31 U.S.C, section Signature: <br />. 1352. This dlscklsure of lobby\ng IIIc1Mtilta Is a material representatiOn 01 fact <br />upon which reliance was placed by the tier aIJovewhllln this tr8nl8ctlon was made Print Name: <br />or entered Into. This dlsdosure is required pursuant to 31 U,S.C. 1352. This <br />lnformaU01 \Mil be reportedtothe Congess sem~annu"y and wII be .....ailabl.for Title: <br />pubic Inspectlm, My person who fans 10 file the requi'ed dlsdD8\H' thall be <br />IUbject to 8 clvn penalty of not lesl thai $10,000 and not more than $100,000 for Telephone No.: Date: <br />each sudl failure. <br />... . .. . ... .... .. .::1 Authorized for Local Reproduction <br />Federal Use Only: . . . .. .. . .. . .. ... . ... Standard Form LLL (Rev. 7-97) <br />