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<br />'0" <br /> <br />',.,.!:;:;.;;.. <br /> <br />'r;";C~"?J;;f.~{W'.f::.;~~jf:l~~~qr~~~~~ <br /> <br />"'" <br />Disclosure of Lobbying Activities <br /> <br />Approved by OMB 034~046 . <br /> <br />Complete this tonn to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Inslructions snd Public Reporting burden statement) <br /> <br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type <br /> o a. contract D a. bid/offer/application o a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Only <br /> d. loan year (yyyy) __ quarter ____ <br /> e. loan guarantee <br /> f. loan insurance dale of last report (mm/dd/yyyy)_____ <br />4. Name and Address 'of Reporting Entity 5. If Reporting Entity in No.4 is Subawardee. enter Name and Address <br /> DPrime o Subawardee Tier __ ,if known: of Prime <br /> Congressional District, if known Congressional District, if known <br />6. Federal DepartmenUAgency 7. Federal Program NamelOescriplion <br /> .. <br /> CFDA Number. if applicable ____ <br />8. Federal Action Number, if known 9. Award Amount, if known <br /> $ <br />10a. Nam,a. and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from No. lOa.) <br /> (if individual, last name, first name, MI) (last name, first name, MI) <br /> .. <br /> <br />11. Amount of Payment (check all that apply) <br /> <br />(attach continuation sheet(s) if necessary) <br />13. Type of Payment (check alllhat apply) <br /> <br />$ <br /> <br />D a. retainer <br />o b. one-time fee <br />o c. commission <br />o d. contingent fee <br /> <br />va'"" --------u----------------=1. B: ~~:::::eCifYL_~::==:---------~~ <br /> <br />14: Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), emplayee(s), ar Member(s) contacted, <br />far Payment Indicated in Item 11 <br /> <br />actual <br /> <br />planned <br /> <br />12. Form of Payment (check alllhat apply) <br /> <br />Da <br />Db <br /> <br />cash <br /> <br />in-kind; specify: nature <br /> <br />15_ Continuation sheets attached DYes 0 No <br /> <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 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 /> <br />Federal Use Only: <br /> <br />(attach continuation sheet(s) if necessary) <br /> <br />~jgnature <br /> <br />Print Name <br /> <br />Title <br /> <br />Telephone No. <br /> <br />Date (mm/dd/yyyy) <br /> <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />