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CONTRACT NO: DISCLOSURE OF LOBBYING ACTIVITIES EXHIBIT H PAGE 2 OF 3 COMPLETE THIS FORM TO DISCLOSE ACTIVITIES PURSUANT TO 31 U.S.C 1352 1. Type of Federal Actions: 2. Status of Federal Actions: 3. Report Type: a. contract a. bid/offer/application a. initial fiiing b. grant b. initial award b. material change c. cooperative agreement c. post-award d.loan For Material Change Only: e. ioan guarantee Year Quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee. Prime Subawardee Enter Name and Address of Prime: Tier :if known: Con~ressional District, if known: Conoressional District, if known: 6. Federal Department / Agency: 7. Federal Program Name/Description: CFDA Number if known: 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10a. Name and Address of Lobbying Entity 1 Db. Individual Performing Services (if individual, iast name, first name, MI): (including address if different from No.1 Oa.) (last name, first name, MI): (attach Continuation Sheets SF-LLL-A, if necessarv) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): a. retainer $ actual olanned b. one-time free 12. Form of Payment (check all that apply): c. commission a. cash d. contingent fee b. in-kind: specify: e. deferred nature: f. other specify: value: 14. Enter 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 on item 11: 15. Continuation sheet(s} SF-LLL-A attached: DYes DNo 16. Information requested through this form authorized by Title 31 U.S.C. Section 1352 This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier Signature: N/A above when this transaction was made or entered into. This disclosure is required pursuant to 31 Print Name: U.S.C 1352. This information will be reported to the Congress semiannually and will be available for Title: pubiic inspection. Any person who fails to file the required disclosure snail be subject to a civil penalty Telephone No. of not less than $ 10,000 and not more than $ 100.000 for each such failure Date: