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Disclosure of Lobbying Activ. '7'-s <br />Complete L11is form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br />1. typo of hecierai Action <br />❑a. contract <br />b. grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />I. 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 Tler , if known: <br />Congressional District, if known <br />a. veoerat uepartment/Agency <br />Approved by OMB 0348-0046 <br />3. Report Type <br />❑a. initial filing <br />b. material change <br />For Material Change Only <br />year (yyyy) quarter <br />date of last report (mmiddlyyyy)_,�_ _ <br />S. If Reporting Entity In No. 4 is Subawardee, enter Name and Address <br />of Prime _ <br />Congressional District, if known <br />7. Federal Program Name/Description <br />CFDA Number, if applicable <br />8. Federal Action Number, if known <br />9. Award Amount, If known <br />100. Name and Address of Lobbying Registrant <br />(if individual, last name, first name, MI) <br />b. Individuals Performing Services (Induding address If different from No. lea.) <br />(last name, first name, MI) <br />(attach continuation beet(s) if necessary) <br />11. Amount of Payment (check all that apply) <br />13. Type of Payment (check all that apply) <br />$ actual <br />punned a. retainer <br />12. Form of Payment (check all that apply) <br />b. one-tlme fee <br />Fla. cash <br />C. commission <br />b. in -kind; specify: nature <br />d. contingeni fee <br />value <br />e. deferred <br />f. other (specify) <br />14. Brief Description of Services Performed or to be <br />for Payment Indicated in Item 11 <br />Performed and Date(s) of Service, Including officer(s), employee(s), or Member(s) contacted, <br />(attach continuation sheets) if necessary) <br />15. Continuation sheets attached 11(attach <br />❑ Na <br />a, fntormation requested through this form is authorized by Sec.319, <br />Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10, Pub. L.104- <br />65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying activities <br />-is a material representation of fact upon which reliance was placed <br />by the above when this transaction was trade 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 <br />for public inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less than $10,000, <br />and not more than $100,000 for each such failure. <br />Signature <br />Print Name - <br />Title <br />Telephone. No. <br />Date (mm/dd/v <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />ATTAPMENT _I TO EXHIBIT C -- PAGE 1 Of 2 <br />