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<br />"'" <br /> <br />"'" <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMB <br />0348-0046 <br /> <br /> See reverse for public burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />o a. contract Oa. bid/offer/application D 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 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 />o Prime o Subaward.. and Address of Prime: <br />Tier ___. if known: <br />Congressional District, if known: Congressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <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, M/): different from No. 10a) <br /> (last name, first name, M/l: <br /> fanach ConMualion Shealfs) SF-LLLA, if necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ------ o aclual o planned o a. retainer <br /> o b. one-time ree <br />12. Form of Payment (check all that apply): D c. commission <br />o a. cash o d. conllngenl fee <br />o b. in-kind; specify: nature ----- o e. deferred <br /> value --- o f. other; specify: <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated In Item 11: <br /> fanach Continuation Sheetfs) SF-LLLA, if necessary) <br />15. Continuation Sheet(s) SF-LLLA attached: DYes ONo <br />16 InfCNTnalion requested through thlll form is authorized by tiUt 31 U.S.C. HctIon Signature: <br />. 1352. This dlsdosulll of lobbying activities II a material repreeenlation of fact <br />upon which reliance was placed by the tier above when this transaction we. made Print Name: <br />or enlllf8d Into. Thl. disdosure 18 requlllld pul8Uanllo 31 U.s.C. 1352. Thi, <br />Informaticn will be reported to the ConI1"IIS semhannualy and will be available for Title: <br />pubHc: Inspectkn. Ally per9Ol\ who falls to RIe tn. requlnM:l dlsdclure shall be <br />subject to 8 civil penalty cfnct less tnal $10,000 and nctmcre tnan $100.000 fer Telephone No.: Date: <br />each such fallure. <br />.. .. ...... .. .... ... .......... ... ... .1 Authorized for Local Reproduction <br />Federal Use Only: ....... .. ..... ... . ... ... . .... Standard Form LLL (Rev. 7-97) <br />... .- <br />