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DISCLOSURE OF 1,(1RBYING ACTIVITIES <br />COMPi,L'fE'f1IIS FORM'1'0131SCI,GSE LOBBYING AC'I'IVITII.S PURSUANT TO 31 U.S.C. 1352 <br />1. Type of Federal Action: 2. Stags of Federal Action: 3. Report Type: <br />at. contract a, bid/offer/application a. initial <br />h. groat b. initialaward b, material eltangc <br />C. Inoperative agreement c. post -award <br />(l, loan For Matterial Ch ge Only: <br />e. loan guarantee year,.,_,_ quarter <br />f. loan insurance date of 1 report <br />4, Name and Address of Deporting Entity 5. If Deporting Entity in No. 4 j Subawardee, <br />Muter lame and Address ' Prime: <br />Prime ® Subawardee <br />Tier , it known <br />Congressional District, if known ('.ongressiona I istrict, if known <br />G, Federal Department/Agency: 7. federal Pr rnin Name/Description; <br />CFD Number, ifapplicable <br />S. Federal Action Number, if known: 9. Ard Amount, if known! <br />10. a. Name and Address of bobby Entity <br />(If individual, last name, first name, NII) <br />Individuals Performing Serviees (including <br />address if different from No. 10a) <br />(last name, first name, MI) <br />(attachCo nuatiun Sheet(s) if necessary) <br />11. Anmuut of Payment (check all #lint ap y) 13, Type off'atyment (check all that apply) <br />$ _® aott;al lannccl a, retainer <br />b, one-time fes: <br />12. Form of Payment (check all Clea apply): I, conimissl(1ez <br />a. cash ._.__�..._ cl. contingent fee <br />b, in-kind-, specify: . Curt; a deferred <br />value-_..----- f, other, specify_ <br />14. Brie I'DescHption of Ser ices Performed or- to be performed and Daate(s) of Service, indodfng <br />of#icer(s), employcc(s) or member(s) contacted, for Payment Indicated in Item 11: <br />(allacln Continuation Shect(s) if neeessary) <br />15. Contiouatio /Sbeet(s) attached: 'Yes � Na <br />16, Information re nested through this form is authorized by <br />Title 3.1 i1.S ,. Section 1352, ']'his disclosure of [nhbying signaturc:� <br />reliance �v placed by the tier above when his transaction �O <br />was made or entered into. 'l'llis disclosure is required Print %fame. <br />pursuant to 31 U,S,C. 1352. This information will be <br />reported to Congress semiannually and will be available Far <br />public inspection. Any person who fails to file the required T tlle: <br />diSelO5nre sha411 be subject to a civil penalty of net less thin <br />$10,000 and not more than 5100,000 i'or each such fuilura. Telephone No., 95 —7 ff �-76Jd bate: <br />Awhorized Por Local Reprod, <br />Federal Use Only., Standard Fora, - 1,11 <br />Slanderd form LLL licr_ 09-12-W <br />