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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 public burden disclosure, 1- Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ❑ a. contract El a. bid/offer/application a. initial filing b. grant b. initial award D b, material change c. cooperative agreement G. post -award For Material Change Only: d.loan e. year _ __--- quarter _ e, loan guarantee date of last report ___.___ f. loan insurance ------- 4. Name and Address of Reporting Entity: 16. If Reporting Entity in No. 4 is a Subawardee, Enter Name ❑ Prime ❑ Subawardee and Address of Prime: Tier ------- if known. Congressional. District, lfknown: Congressional District, ifknown: 6. Federal Department/Agency: 7. Federal Program NamelDescriptian: 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 (Itindividual, last name, first name, Ml): different from No. 10a) (last name, first name, Ml): (attach Continuation Sheets)SF-LLLA, Ifnecessa ) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ —_____---- ❑ actual ❑ planned ❑ a. retainer ❑ 12. Form of Payment (check all that apply): ❑ b. one-time feec. commission 11 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 Sheet(s) SF-LLLA, if necessary) % Continuation Sheets SF-LLLA attached: ❑ ves ❑ No 16. Informaion requested through this form Is authorized by title 31 U.B.C. seotlon 1352 This disclosure of lobbying adivalas is a material representatlo r of fad Signature: upon which reliance was placed bythe tler above when this transaction was made or entered Into. This disclosure Is required pursuant to 31 U.S.C. 1352. This Print Name: InformaAan will be reported to the Congress semi•annuely and will be avallabla for publo Inspectim. Any person who fails to 018 the requlmd disclosure shall be Title: subject to a civil penally of MUM that $10,000 and not more than $100,000 for each such failure. Telephone No.: _-------- Date: ederSl USe Orlly Authorized for Loeal Reproducfian Standard Form LLL (Rev. 7-97)