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DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348o046 <br />See reverse for public burden disclosure.) <br /> <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3,' Report Type: <br /> contract <br /> a. bid/offer/application ~ a. initial filing <br /> ~' ' b. grant I =b. initial award~ [ b. material change <br /> c. cooperative agreement c. post-award For Material Change Only: <br /> d. loan year quarter <br /> e. loan guarantee date of last report <br /> f. loan insurance <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br /> [] Prime [] Subawardee and Address of Prime: <br /> Tier _, ifknown: <br /> Con~lressional District, if known: Con~lressional District, if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> <br /> CFDA Number, if applicable: _ <br /> 8. Federal Action Number, if known: 9. Award Amount, if known: <br /> $ <br /> 10. a, Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br /> (if individual, last name, first name, MI): different fr~m No. l Oa ) <br /> (last name, first name, MI): <br /> (attach Continuation Sheet(s) SF-LLLA, if necessaq/) <br /> 11. Amount of Payment (check ali that apply): ~ 13. Type of Payment (check ali that apply): <br /> $ [] actual [] planned [] a, retainer <br /> [] b. one-time fee <br /> 12. Form of Payment (check all that apply): [] c. commission <br /> [] a. cash [] d. contil3gent fee <br /> [] b. in*kind; specify: nature. [] e. deferred <br /> value [] f. othe~ specify: <br /> <br /> 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including o~cer(s), <br /> employee(s), or Member(s) contacted, for Payment Indicated in Item 11: <br /> (attach Con~nuaO~)n Sheet(s) SF-LLLA, if necessary) <br /> 15. Continuation Sheet(s) SF-LLLA attached: [] Yes [] No <br />16 Information reques~d ~hro~gh ~is fon~ ;s authorized by litle 31U.S.C section Signature: <br /> each su~ faille. Telephone No.: Date: <br /> Federal USe OnlY:I Authorized for Local Reproduction <br /> <br /> <br />