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<br />, , <br /> <br />..jsclosure of Lobbying Activ~s <br /> <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and PubUc Reporting burden statement) <br /> <br />Approved by OMB 0348-0046 <br /> <br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type <br /> o a. contract o a bid/offer/application o 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 (yyyy) quarter <br /> e. loan guarantee <br /> f. loan insurance dale of last report (mmlddlyyyy) <br />4. Name and Address of Reporting Entity 5. It Reporting Entity In No.4 Is Subawardee. enter Name and Address <br /> OPrime o Subawardee Tier . if known: of Prime 0 _. <br /> Congressional District, if known Congressional District, if known <br />6. Federal Department/Agency 7. Federal Program NamelDeactlptlon <br /> CFDA Number, if applicable <br />8. Federal Action Number, if known 9. Award Amount, If known <br /> . $ <br />10a Name and Address of lobbying Registrant b. .lndMdualsPerfonnlngServlces(lncluding address H different from No. lOa.) <br /> fd Individual. last name, first name, MI) (last name, first name, MI) <br /> <br />12. Fonn of Payment (check all that apply) <br />o a. cash <br />o b. in-kind; specify: nature <br />value <br /> <br />(attach oonMuallon _(0) H neoessary) <br />13. Type of Payment (check an that apply) <br /> <br />o a. retainer <br /> <br />o b. one-time fee <br /> <br />o c. commission <br /> <br />o d. contingent fee <br /> <br />o e. deferred <br /> <br />o f. other (speoify) <br /> <br />14. Brief Description of Services Perfonned or to be Perfonned and Date(s) of Service, Including offlcer(s~ employee(s), or Member(s) contacted, <br />for Payment Indicated In Item 11 <br /> <br />planned <br /> <br />11. Amount of Payment (check all that apply) <br />$ actual <br /> <br />(attach continuation sheet(s) if necessary) <br /> <br />15. Continuation sheets attached 0 Yes 0 No <br /> <br />16.lnlormation requested Ihrough Ihis form is aulhorized by See.31g, <br />Pub. L. 101-121,103 Slat. 750, as amended by sec. 10; Pub. L.104- Signature <br />65, Slat. 700 (31 U.S.C. 1352). This disclosure 01 lobbying activities <br />is a material representation of fact upon which reliance was placed Print Name' <br />by the above when this transaction was made or entered inlo. This <br />disclosure Is required pursuanllo 31 U.S.C. 1352. This informalion TiUe <br />will be reported to the Congress semiannually and will be available <br />lor public inspection. Any person who faiis 10 lile Ihe required Telephone No. <br />disclosure shall be subject to a civil penalty of not less Ihan $10,000 <br />and not more than $100,000 lor each such failure. Date (mmlddlyyyy) <br /> <br /> <br /> <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />