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Exhibit 4 <br /> <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose activities pursuant to 31 U.S.C 1352 <br />1. Type of Federal Actions: <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 Actions: <br /> a. bid/offer/application <br /> b. initial award <br /> c. post-award <br />3. Report Type: <br /> a. initial filing <br /> b. material change <br /> <br />For material change only: <br />Year: Quarter: <br />Date of last report: <br />4. Name and Address of Reporting Entity <br /> Prime Subawardee <br /> <br /> Tier if known <br /> <br /> Congressional District, if known: <br />5. If Reporting Entity in No. 4 is a Subawardee: <br /> Enter Name and Address of Prime: <br /> <br /> <br /> <br />Congressional District, if known: <br />6. Federal Department / Agency: 7. Federal Program Name/Description <br /> <br /> <br />8. Federal Action Number, if known: <br /> <br /> <br />9. Award Amount, if known: <br /> $ <br />10a. Name and Address of Lobbying Entity <br /> (if individual, last name, first name, MI): <br /> <br /> <br /> <br /> <br />(attach Continuation Sheets SF-LLL-A, if necessary) <br />10b. Individual Performing Services <br /> (including address if different from No. 10a) <br /> (last name, first name, MI): <br /> <br /> <br /> <br /> <br />11. Amount of Payment (check all that apply): <br />$ Actual <br /> Planned <br />13. Type of Payment (check all that apply) <br /> a. retainer <br /> b. one-time free <br /> c. commission <br /> d. contingent fee <br /> e. deferred <br /> f. other specify: <br /> <br />12. Form of Payment (check all that apply): <br /> a. cash <br /> b. in-kind: specify: <br />nature: <br /> value: <br />14. Enter Description of Services performed or to be Performed and date(s) of Service, including officer(s), employee(s), or Member(s) <br /> contacted, for Payment indicated on item 11: <br /> <br />15. Continuation sheet(s) SF-LLL-A attached: Yes No <br />16. Information requested through this form authorized by Title <br />31 U.S.C. Section 1352. This disclosure of lobbying activities is a <br />material representation of fact upon which reliance was placed by the <br />tier above when this transaction was made or entered into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. This information <br />will be reported to the Congress semiannually and will be available for <br />public inspection. An person who fails to file the required disclosure <br />shall be subject to a civil penalty of not less than $10,000 and not <br />more than $100,000 for each such failure. <br /> <br />Signature: <br /> <br /> <br />Print Name: <br />Title: <br />Telephone No: <br />Date: <br />