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DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reversp fnr nl lhlir hi irricn dieriner..e \ Approved by OMB 0348-0046 1. Type of Federal Action: 2. Status of Federal Action: V vV 3. Report Type: a. contract b. F-1a. bid/offer/application a. initial filing grant b. initial award b. 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______, if known: Congressional District, if known: Congressional District, if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: 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, first name, MI): different from No. 10a) (last name, first name, Ml): (attach Continuation Sheets) SF-LLLA, if necessary) 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $❑ 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 Sheet(s) SF-LLLA, if necessary) 15. Continuation Sheets SF-LLLA attached: ❑ Yes ❑ No 16 lmonnation requested through this form is authodxed by title 31 U.S.C. section 1352. This disclosure of bbbying actinfies Is a material representation & fact Signature: upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This Print Name: information will be reported to the Congress semi-annually and will be available for public Inspection. Any person who fails to file the required disclosure shall be Title: subject to a civil penalty of not less Met $10,000 and not more than $100,000 for Telephone No.: Date: each such failure. Federal Use, Only: Authorized for Local Reproduction Standard Form LLL (Rev. 7-97)