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DISCLOSURE OF LOBBYING ACTIVITIES <br />ORNI TO DISCLOSE LOBBYING ACTIVITIES PURSUANT <br />1. Type of Federal Action: <br />® a. contract <br />b. grant <br />C. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f, loan insurance <br />2. Status of Federal Action: <br />® a. bid/offer/application <br />b. initial award <br />C, post -award <br />4. Name and Address of Reporting Entity <br />Prime ❑ Subawardee <br />Tier— r U. � EL � COW Tier— z JIL-MM VENUE <br />WNG S CH' MPongressional District, if lotown <br />6. Federal Department /Agency: <br />S, Federal Action Number, if known: <br />, if known <br />1.0. a. Name and Address of Lobby Entity <br />(If individual, last name, first name, MI) <br />3. Report Type: <br />a. initial <br />b. material change <br />For Material Change Only: <br />year_ quarter _ <br />date of last report _ <br />5. If Reporting Futity in No. 4 is Subawardee, <br />Enter Name and Address of Prime: <br />Congressional District, if known <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable <br />9. Award Amount,ifknown: <br />b. Individuals Performing Services ('including <br />address if different from No. IOa) <br />(last name, first name, MI) <br />(attach Continuation Sheet(s) if necessary) <br />11. Amount of Payment (cheek all that apply) <br />$ ❑ actual ❑ planned <br />12. Form of Payment (cheek all that apply): <br />ea. cash ` <br />b. in -kind; specify: nature <br />value <br />13. Type of Payment (check all that apply) <br />a. retainer <br />b. one -time fee <br />c. commission <br />d. contingent tee <br />e deferred <br />f. other, specify__ .. <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including <br />off;eer(s), employee(s), or member(s) contacted, for Payment Indicated in Item it: <br />(attach Continuation Sheets) if ne ssary) <br />15. Continuation Sheet(s) attached: Yes 0 Na <br />16. Information requested through this form is authorized by <br />Title 31 U.S.C. Section 1352. This disclosure of lobbying <br />reliance was placed by the tier above when his transaction <br />was made or entered into. 'this disclosure is required <br />pursuant to 31 U.S. C. 1352. This information will be <br />reported to Congress semiannually and will be available for <br />public inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less than <br />,610,000 aid not more than $100,000 for each such failure. <br />Federal Use <br />Print Name: <br />Telephone No.: 699-5341 __ <br />23A -33 <br />Authorized for Local Reproduction <br />Standard Form - LL.L <br />