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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> 0348-0046 <br /> Complete the form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> (See reverse for public burden disclosure.) <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> ? a. contract a. bid/offer/application ? a. initial filing <br /> b. grant ? b. initial award b. material change <br /> c. cooperative agreement c. post-award <br /> d. loan For Material Change Only: <br /> e. loan guarantee year quarter <br /> f. loan insurance date of Last report <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name <br /> and Address of Prime: <br /> ? Prime ?Subawardee <br /> Tier , if known: <br /> Congressional District, if known: Congressional District, if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, Ifapplicab/e: <br /> 8. Federal Action Number, if known: 9. Award Amount, ifknown: <br /> 10. a. Name address of Lobbying Entity b. Individuals Performing Services (including address if <br /> (if individual, last name, first, name, MI): different from No. 10a) <br /> (last name, tryst name, MI): <br /> (attach Continuation Sheet(s) SF-LLL-A, if necessary) <br /> 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br /> ? a. retainer <br /> ? actual ? planned ? b. one-time fee <br /> 12. Form of Payment (check all that apply): ? c. commission <br /> ? a. cash ? d. contingent fee <br /> ? b. in-kind; specify: nature ? e. deferred <br /> Value <br /> ? f. other; specify: <br /> 14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or <br /> Member(s), contacted, for Payment indicated in Item 11: <br /> (attach Continuation Sheet(s) SF-LLL-A, if necessary) <br /> <br /> 15. Continuation Sheets SF-LLL-A attached: ? Yes ? No <br /> 16. Information requested through this form is authorized by Signature: <br /> Title 31 U.S.C. section 1352. This disclosure of lobbying <br /> activities is a material representation of fact upon which Print Name: <br /> reliance was placed by the tier above when this <br /> transaction was made or entered into. This disclosure is Title: <br /> required pursuant to 31 U.S.C. 1353. This information will <br /> be reported to the Congress semi-annually and will be <br /> available for public inspection. Any person who fails to <br /> file the required disclosure shall be subject to a civil <br /> penalty for not less than 510,000 and not more than <br /> X100,000 for each failure. Telephone No.: Date: <br /> FederaF Use Onlyr Authorized for Local Reproductions <br /> Standard Form -LLL <br /> 25~-38 <br /> <br />