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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying aclivilies pursuant to 31 U.S.C. 1352 0348 -0046 <br />(See reverse for public burden disclosure.) <br />1. Type of Federal Action: <br />❑ <br />2. Status of Federal Action: <br />3. Report Type: <br />a. contract <br />❑ a. bld/offer /application <br />❑ a. initial filing <br />b. grant <br />b. initial award <br />b. material change <br />a cooperative agreement <br />c. post -award <br />For Material Change Only: <br />d. loan <br />e. loan guarantee <br />year quarter <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />❑ Prime <br />5. If Reporting Entity In No. 4 is a Subawardee, Enter Name and Address <br />❑ Subawardee <br />of Prime: <br />Tier if known: <br />Congressional District, if known: <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name /Description: <br />CFDA Number, if applicable: <br />S. Federal Action Number, if known: <br />9, Award Amount, if known: <br />5 <br />10. a. Name and Address of Lobbying I3, Individuals Performing Services ( including address <br />Entity <br />if different from No. 10a) <br />(If individual, last name, first name, Ml): (last name, first name, MI): <br />(attach Continuation Sheet(s) SF -LLLA, if necessary) <br />11. Amount of Payment ( check all that apply): <br />13. Type of Payment ( check all that apply): <br />S ❑ actual ❑ planned <br />❑ a. retainer <br />❑ b. one -time fee <br />❑ c. commission <br />❑ d. contingent fee <br />12. Form of Payment ( check all that apply): <br />❑ a. cash <br />❑ b. in -kind: specify: nature <br />❑ e. deferred <br />C1 f. other; specify: <br />value <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including <br />officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br />attach Continuation Sheets SF -LLi.A if necessary) <br />15. Continuation Sheet(s) SF -LLLA attached: Yes LJ No <br />16. <br />Information requested through this form is authorized by title 31 <br />Signature: <br />Print Name: <br />U.S.C. secllonl352. This disclosure of lobbying_activities Is a <br />Title: <br />material representation of fact upon which reliance was placed <br />Telephone No.: Date: <br />by the tier above when this transaction was made or entered <br />into. This disclosure Is required pursuant to 31 U.S.C. 1352. This <br />Information will be reported to the Congress semi - annually and <br />will be available for public inspection. Any person who fails to rile <br />the required disclosure shall be subject to a civil penalty of not <br />less that $10,000 and not more than $100,000 for each such <br />failure. <br />Federal Use Only: <br />Authorized for Local Reproduction <br />Standard Form LLL_(Rev. 7 -97) <br />EXHIBIT B <br />