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~ ,,~., ,~, ~ . "" Disclosure of Lobbying Activities .:.,,~~,~~'W~~~~,~~! Approved by OMB 0348.()046 Complele this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden statement) 1. Type of Federal Action 2. Status of Federal Action 3. Report Type o a. contract D a. bid/offer/application D a. initial filing b. grant b. inHial award b. material change c. cooperative agreement c. post-award For Material Change Onfy d. loan year (yyyy) quarter__ e. loan guarantee I. loan insurance date of last report ('"!f"ddIyyyy) - -, If Reporting Entity In No.4 Is Subawardee. enter Name and Address 4. Name and Address of Reporting Entity 5. DPrime DSubawardee Tier , if known: of Prime Congressional District, if known Congressional District, if known 6- Federal Department/Agency 7. Federal Program NamelDescriptlon - CFDA Number, If applicable 8. Federal Action Number. if known 9. Award Amount, If known $ 10a. Name and Address of Lobbying Registrant b. Individuals Perfonning Services (including address if different from No. tOa.) (if individual, last name, first name, MI) (last name, first name, Ml) (attach continuation sheet(s) if necessary) 11. Amount of Payment (check an that apply) 13. Type of Payment (check all that apply) $ actual planned D 8. retainer 12. Form of Payment (check all that apply) D b. one.f1me fee o a. cash D c. commission o b. in-kind; specify: nature 0 d. contingent fee value 0 e. deferred D f. other (specify) 14. Brief Description of Services Performed or to be Performed and Date(s) of service1 including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11 (attach continuation slleet(s) if necessary) 15. Continuation sheets attached 0 Ves D No 16. Information requested through this form is authorized by See.319, Pub. L. 101-121. 103 Stat. 750, as amended by sec. 10; Pub. L. 104- Signature 65, Stat. 700 (31 U.S.C. 1352). This disclosure of lobbying aelivities is a material representation of fact upon which reliance was placed Print Name by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information TItle will be reported to the Congress semiannually and will be available for public inspection. Any person who fails to file the reqUired Telephone No. disclosure shall be subjeelto a civil penally of not less than $10,000 and not more than $100,000 for each such failure. Fell"....I'llse'Only: Authorized for Local Reproduction Standard Form-LLL (7/97)