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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ? a. contract ? a. bid/offer/application ? a. initial filing b. grant b. initial award b, material change c. cooperative agreement c. post-award For Material Change Only: d. loan year quarter e. loan guarantee date of last report f. loan insurance - 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name and Address ? Prime ? Subawardee of Prime: Tier if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number, if applicable: 8. Federal Action Number, if known: 9. Award Amount, if known: 10. a. Name and Address of Lobbying b. Individuals Performing Services ( including address Entity if different from No. 10a) ( if individual, last name, first name, MI): (last name, first name, MI): (attach Continuation Sheet(s) SF-LLLA, if necessary) 11. Amount of Payment ( check all that apply): 13. Type of Payment ( check all that apply): $ ? actual ? planned ? a, retainer ? b. one-time fee ? c. commission 12. Form of Payment ( check all that apply): ? d. contingent fee ? a. cash ? e. deferred ? b. in-kind; specify: nature ? f. other; specify: value 14. Brief 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 in Item 11: (attach Continuation Sheet(s SF-LLLA, if necessary) 15. Continuation Sheet(s) SF-LLLA attached: ? Yes ? No 16. Signature: Information requested through this form is authorized by title 31 Print Name: U.S.C. section1352. This disclosure of lobbying activities is a Title: material representation of fact upon which reliance was placed Telephone No.: Date: by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any person who falls to file the required disclosure shall be subject to a civil penalty of not less that $10,000 and not more than $100,000 for each such failure. Authorized for Local Reproduction Federal Use Only: Standard Form LLL Rev. 7-97) EXHIBIT B