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....., \....,; DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 Approved by OMS 0348-0046 'See reverse for nubile burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: o a. contract 'Oa. bid/offer/application o 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 o Prime D Subawardee and Address of Prime: Tier ___, if known: Conoressional District, if known: Conaressianal District, if known: 6. Federal Department/Agency: 7. Federal Program NamelDescription: CFDA Number, if applicable: 8. Federal Action Number, if known: 9. Award Amount, if known: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (ifindividual, last name, first name, MI): differentfrom No. IDa) (last name, first name, MI): (attach Continuation Sheet(s) SF-LLLA, if necessary} 11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): $ ---- o actual o planned o a. retainer o b. one-time fee 12. Form of Payment (check all that apply): o c. commission o a. cash o d. contingent fee o b. in-kind; specify: nature -- o e. deferred value o f. other; specify: . 14. Brief Description of Services Performed or to be Performed and Date(s) af Service, including afficer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11: (attach Continuation Sheet(s) SF-LLLA. ifnecessary) 15. Continuation SheetiSl SF-LLLA attached: DYes ONo 16 Information requested through this form Is authorized by tiUs 31 U.S.C. section Signature: . 1352. This disdosure of Iob~ng activities Is a material representation of fad: upon which reliance was placed by the tier above when this transacUon was made Print Name: or eotered into. This <Ii$do5Ure Is rvquirad pultluant 10 31 U.S.C. 1352. This Informalkn will be reported to the Con{1eSS seml-annualy and wHI be available for Title: public inspectia1. Ivly person who feils to file the requi'ed disdosure shall be subjec.1 to a civil penalty of not less that $10,000 and not more than $100.000 for Telephone No.: Date: esch suctl failure. Federal Use Only: I Authorized for local Reproduction Stand.1ll Fonn LLL (Rev. 7-97)