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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 oublic burden disclosurP.l 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract �a. bid/offer/application a. initial filing 1:1b. b. grant b. initial award 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 ❑ Prime ❑ Subawardee and Address of Prime: Tier I if known: Congressional District, if known: Congressional District, if known: 6. Federal DepartmentlAgency: 7. Federal Program NamelDescription: CFDA Number, if applicable: 8. Federal Action Number, if known: 9. Award Amount, if known: 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, fast name, Ml): different from No. 90a) ( last name, first name, 1141): {attach Continuation Sheets) SF-LLLA, if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): __—W_ ❑ actual ❑ planned ❑ a. retainer ❑ b. one-time fee ❑ c. commission 12. Form of Payment (check all that apply): ❑ a. cash ❑ d, contingent fee ❑ b. in -kind; specify: nature ❑ e. deferred value ---------- ❑ f. other; specify. 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 Sheef(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16.Information requested through this form Is authorized by title 31 U.S.C. section 1352, This disclosure of lobbying activities Is a material representation of fad Signature: upon which reliance was placed by tho Her abovewhen this transaction was made or entered into. This disclosure Is required pursuant to 31 U.S.C, 1362. This print Name: information will be reported to the Congress sorri annually and will be avaliable for public inspection. Any person who falls to file the requi disclosure shall be Title: subject to a civil penalty of not less that $10,000 and nut mnre than $100,000 for each such fallure. Tele hone No.: Date•, p---------------------- Date: Federal Use Only: Authorized f Local uciio or Reproduction Standard Form LLL (Rev. 7-97)