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Q" Iosuee of Lobbying Activitir <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br />Approved by OMB 0348-0046 <br />1. Type of Federal Action <br />2. Status of Federal Action <br />3. Report Type <br />❑a. contract <br />b. <br />a. bid/offer/application <br />❑ <br />a: initial filing <br />❑ <br />grant <br />b. initial award <br />b, material change <br />c. cooperative agreement <br />d. loan <br />c. post -award <br />For Material Change Only <br />e. loan guarantee <br />year (yyyy) quarter <br />f. loan insurance <br />date of last report (mm/ddlyyyy) <br />4. Name and Address of Reporting Entity <br />5. If Reporting Entity In No. 4 Is Subawardee, enter Name and Address <br />❑ Prime .. ❑ Subawardee Tier if known: <br />of Prime <br />Congressional District, if known <br />Congressional District; if known <br />6. Federal Department/Agency <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 />10a. Name and Address of Lobbying Registrant <br />b. IndividuafsPerformingServices(includingaddress€tdifferentfromNo. ioa.) <br />(if individual, last name, first name, MI) <br />(last name, first name, MI) <br />conunuauon sneet(s) It <br />11. Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) <br />$ actual. planned ❑ a. retainer <br />12. Form of Payment (check all that apply) : ❑ b. one-time fee <br />❑ a. cash .❑ C. commission <br />❑ b. in kind; specify: nature ❑ d, contingent fee <br />value ❑ e. deferred <br />❑ f. other (specify) <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), empioyee(s), or Member(s) contacted, <br />for Payment Indicated In Item 11 <br />(attach continuation sheet( <br />15. Continuation sheets attached ❑ Yes ❑ No <br />16. Information 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 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 <br />for public inspection. Any person who falls to .file the required <br />disclosure shall be subject to a civil penalty of not less than $101000 <br />and not more than $100,000 for each such failure. <br />if necessary) <br />Signature <br />Print Name <br />Title <br />Telephone No. <br />Date <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />ATTArHMFn.IT Tn FYHTRT`t' r <br />