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, ' '-' '...I DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U,S,C, 1352 Approved by OMB 0348-0046 See reverse for nublic burden disclosure,) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: o a, contract Da, bid/offer/application D a, initial filing b, 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 Op'lme o Subawardee and Address of Prime: Tier ----. if known: Conllressional District, if known: Conllressional 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, ifknown: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (ifindividual, last name, first name, M/): different from No. 10a) (last name, first name, M/): (attach Continuation Sheet(s) SF-LLLA, if necessary) 11. Amount of Payment (check all that appiy): 13. Type of Payment (check all that apply): $ ---------- o actual o plenned o 8. retainer o b. one-time fee 12. Form of Payment (check all that appiy): D c. commission o a. cesh o d. contingent fee o b. in-kind; specify: nature --------- o e. deferred value -------- o f. other; specify: ___________________ 14. Brief Description of Services Perfonmed or to be Perfonmed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Confinuation Sheet(s) SF-LLLA, if necessary) 15. Continuation SheeUsl SF-LLLA attached: DYes ONe 16 Information requested through this form is autholized by title 31 U.S.C. section Signature: . 1352, thIS dlSclostlfll of lobbYing aclIViije5 is a mElteria! representation of fact upon which reliance was placed by the tier above when this transaction was made Print Name: or entered into. This di&dosure is required pursuant to 31 U.S.C. 1352. This information will be reported to the Congress semi-annually and wi~ be available for Titie: public Inspection. Any pl!l'SOO who fails to file the required disclosure shall be subjecl to a civil penalty of not less that $10,000 and not more than $100,0 00 for Telephone No.: Date: each such failure. Federal Use Only: I Authorized for Local Reproduction Standard Form Lll (Rev. 7-97)