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'-' '-" 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 cublic burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: D 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 o Prime o Subawardee and Address of Prime: Tier ___, if known: Congressional District, if known: Congressional 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, if known: $ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if (if individual, last name, first name, Mi): different from No. IDa) (last name, first name, M/): (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 D 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) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated In Item 11: (attach Continuation Sheet(s) SF.LLLA, ifnecessary) 15. Continuation Sheet(s) SF-LLLA attached: o Yes ONo 16 Information requested through thia form Is authorized by ijUe 31 U.S.C. section Signature: . 1352 This dlsdoSUf8 of lobbying activities is a material representation at fact upon which reliance was placed by the tier above when this transaction was made Print Name: or enl8f'ed into. This disdosure is required pursuant to 31 U.S.C. 1352. This infolm8.ticn will be reported to the COn!J'8S8 semi-annualy and wlll be available for Title: pubHc inspectiO'l. MY person who fails to file the required disdOllure shall be subject to a civil penalty of not less that $10,000 and not more than $100.000 for Telephone No.: Date: each such failure. Federal Use Only: I Authorized for Local Reproduction Standard Form LLL (Rev. 7.97)