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DISCLOSURE OF LOBBYING ACTIVITIES <br />Complele this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for public burden disclosure) <br />a. contract a. md/offer/applicatlon a. Initial filing <br />b. grant b. Initial award <br />b. material change <br />o, cooperative agreement c, post -award <br />For Material Chungs Only, <br />d, loan <br />year quarter <br />e. loan guarantee <br />date of last report <br />f. loan Insurance <br />4. Name and Address of Reporting Entity: 6. <br />If Reporting Entity in No, d Is a Subawardeo, <br />Prime Subawardee <br />Enter Name and Address of Prime: <br />Tier , if known; <br />Congressional Distriat, ff known: Congressional District, If known., <br />6, Federal Department/Agency: 7. Federal Program Name/Description. <br />CFDA Number if applloable: <br />S, Federal Action Number, lfknown: g. Award Amount, Ifknown: <br />10,a. Name and Address of Lobbying Entity <br />(if individual, last name, first name, MI): <br />11. Amount of <br />12, Form of Payment (check all that <br />a. cash <br />b. In -kind; specify: nature _ <br />value <br />or <br />offlcor(s), employea(s) or <br />If different from No. <br />b, one-time fee <br />r,, commission <br />d, contingentfee <br />a. deferred <br />f. other: sWeclfv: <br />Payment Indicated on Item 11: <br />ress <br />16. information requested through this form In authorized by <br />Title 31 U,S.C. Section 1952, This disclosure of <br />Signature: <br />lobbying activiffes Is a material representation of foot <br />upon which reliance was placed by the der above whom <br />print Name: <br />this transaction was made or entered into. This dis- <br />dosure Ia required pursuant to 31 U.S.C. 1352. This <br />Title: <br />information will be reported to the Congress semi- <br />annually and will be available for public htspecllon. Any <br />person who falls to file the required disclosure shall be <br />Telephone No.: Date: <br />subject to a civil penalty of not less than $10,000 and <br />not more than $100,000 far each such fafiure, <br />INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES <br />Federal Use Only: Authorized for Local IZmproduotlon <br />Standard Form - LLLA (Rev. 7-97) <br />