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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. 1362 <br />See reverse for public burden disclosure. <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />El a. contract 11 a. bldlofferlapplication ? 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 /> <br />? <br />13 and Address of Prime: <br />Suhawartlee <br />Prime <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, If applicable: <br />6. Federal Action Number, if known: 9. Award Amount, if known: <br /> <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, first name, MV: <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 /> <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 />? <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, ifnecessary) <br />15. Continuation Sheets SF-LLL-A attached: 0 Yes 0 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 $10,000 and not more than <br />$100,000 for each failure. Telephone No.: Date: <br />Federal Use Only: <br />I <br />Authorized for Local Reproductions <br /> Standard Form - LLL <br />F2