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<br />: ~l , <br />~',",", . <br /> <br />..-..,.,'..,'........;............,.. <br /> <br />'-' <br /> <br />-....I <br /> <br />1. Type of Federal Action: <br />o a. contract <br />b. grant <br />c. cooperative agreement <br />d.loan <br />e. loan guarantee <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />D Prime D Subawardee <br />Tier ___' ifknown: <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this fonn to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />See reverse for ublic burden disclosure. <br />2. Status of Federal Action: 3. Report Type: <br />Oa. bid/offer/application 0 a. initial filing <br />b. initial award b. material change <br />c. post-award For Material Change Only: <br />year quarter _____ <br />date of last report <br /> <br />Approved by OMS <br />0348-0046 <br /> <br />5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br />and Address of Prime: <br /> <br />Con ressional District, if known: <br />6. Federal Department/Agency: <br /> <br />Con ressional District, if known: <br />7. Federal Program Name/Description: <br /> <br />CFDA Number, if applicab/e: <br /> <br />10. a. Name and Address of Lobbying Entity <br />(if individual, last name, first name, MI): <br /> <br />9. Award Amount, if known: <br /> <br />$ <br /> <br />b. Individuals Performing Services (including address if <br />different from No. 10a) <br />(/astname, first name, M/): <br /> <br />8. Federal Action Number, if known: <br /> <br />lattach ConUnuation Sheet(s) SF-LLLA, if nsee..e ) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br /> <br />$ ___ D actual D plenned D a. retainer <br />o b, one-time fee <br />o c. commission <br />D d. contlngenllee <br />D e. delerred <br />D f. olher; speCify: <br /> <br />12. Form of Payment (check all that apply): <br />D a. cash <br />D b. in-kind: specify: <br /> <br />nature <br />value <br /> <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 /> <br />(aUaell C<>nUnuaUon Shee/(s) SF-LLLA, If nseessa ) <br /> <br />15, Continuation Sheet s SF.LLLA attached: D v.. D No <br /> <br />16 InformaUon reqtHt5lecl through lhls form Ia lIUthorIzed by tiUe 31 U.s.C. section Signature' <br />. 1352. Thb! disclOlUre of Iabtrjlng activities Is . malerlll repre..nllltlon of fact' . <br />uponwhlc:t1re1lanCewuplacadbylheUllrabovewhenlf1l1lransac:tionwumllda p' t N <br />or emered Into. Thll disclosure il required plnUBnllo 31 U.s.C. 1352. ThIl nn sma: <br />InIormallcn wm be reported b !he ContJ8U I8ITlJ-aMuaIy and wi! be avalllbla for <br />pubic lnIpec::tIa1. Any perIOrl wna fslb! to llle the requncl dlsdosu.. IhaII be Trtle: <br />IUbIect b a civil penalty of not lesslhal. $tO,Ooo and not mora thin $100.000 (or <br />eo"'.... 10'..., Telephone No.: <br /> <br /> <br />Fe,del'llll.!~~Ollly: <br /> <br /> <br />Date: <br /> <br />Authorized for Local Reproduction <br />Standard Fonn LLL (Rev. 7-97) <br />