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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <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 For Material Change Only: <br />d. loan year quarter <br />e. loan 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 and Address <br />? Prime$ Subawardee of 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 />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> <br />10. a. Name and Address of Lobbying b. Individuals Performing Services ( including address <br />Entity if different from No. 10a) <br />( if individual, last name, first name, MI): (last name, first name, MI): <br />(attach Continuation Sheet(s) SF-LLLA, if necessary) <br />11. Amount of Payment ( check all that apply): 13. Type of Payment ( check all that apply): <br />$ ? actual ? planned ? a. retainer <br /> ? b. one-time fee <br /> ? c. commission <br />12. Form of Payment ( check all that apply): ? d. contingent fee <br />? a. cash ? e. deferred <br />? b. in-kind; specify: nature ? 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-LLLA, if necessary) <br />15. Continuation Sheet(s) SF-LLLA attached: Yes ? N Idd% <br />16. Signature: <br />Information requested through this form is authorized by title 31 Print Name: R Rodrl e z . D. <br />U.S.C. section 1352. This disclosure of lobbying activities is a Title: <br />material representation of fact upon which reliance was placed Telephone No.:71 4-490-74 te: <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 file <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 /> Authorized for Local Reproduction <br />Federal Use Only: Standard Form LLL (Rev. 7-97 <br />EXHIBIT C <br />DO-12-1722-01