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<br />'-' <br /> <br /> <br />Disclosure of Lobbying Activities <br /> <br />Complete this form to disclose lobbying activities pursuant 10 31 U.S.C. 1352 <br />(See reverse side for Instructions and Public Reporting burden statement) <br /> <br />Approved by OMS O~6 <br /> <br />1. Type of Federal Action 2. Statu. of Federal Action 3. Report Type <br /> o a. contract o a. bid/offer/applicafion o a.lnlfial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award For Material Change Only <br /> d. loan yaar (yyyy) quarter <br /> e. loan guarantee <br /> l. loan insurance data of last repert ("'!"iddlyyyy)_____ <br /> - -, If Reporting Entity In No. 4 Is Subawardee. enter Name and Address <br />4. Name and Address of Reporting Entity 5. <br /> OPrime o Subawardee lier , if known: of Prima <br /> Congressional District. if known Congressional District, if known <br />6. Federal Department/Agency 7. Federal Program NameIDescriptlon <br /> - <br /> CFDANumbar,W~~ <br />8. Federal Action Number, if known 9. Award Amcun~ W known <br /> $ <br />10a. Name and Address of lobbying Registrant b. Individuals Perlonning Services (tneluding address if (f1fferent from No. 10a;) <br /> (if individual, last name, first name, MI) (last name, first name, MI) <br /> <br />11. Amount of Payment (check an thalappl}') <br />$ actual <br />12. Form of Payment (check all that apply) <br />D a. cash <br />D b. in-kind; specify: nature <br />value <br /> <br />(attach continuation sheet{s) if necessary) <br />13. Typo of Payment (c:hack all thaI apply) <br /> <br />Oa.11llaInar <br /> <br />D b. one-time fee <br /> <br />D c. commission <br /> <br />D d. contingent fee <br /> <br />D e. deferred <br /> <br />o f. other (specify) <br /> <br />planned <br /> <br />14. Brief Description of Services Performed or to be Performed and Data(s) of Service, including officer(s), employee{s), or Member(s) contacted, <br />for Payment Indicated in Item 11 <br /> <br />(attach continuation sheet(s) if necessary) <br /> <br />15. Continuation sheets attached DYes D No <br /> <br />16. Information requested through this form is authorized by Sec.319, <br />Pub. L. 101-121, 103 Stal. 750, as amended by sec. 10; Pub. L. 104- Signalure <br />65, Stal. 700 (31 U.S.C. 1352). This disclosure of 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 pursuant to 31 U.S.C. 1352. This information Title <br />will be reported to the Congress semiannually and will be available <br />for public inspection. Any person who fails to file the required Telephone No. <br />disclosure shall be subject to a civil penalty of not less than $10,000 <br />and not more than $100,000 for each such failure. Data (mm/ddlyyyy) <br /> <br />Federal1Jse;<lnly: <br /> <br /> <br />Authorized for Local Reproduction <br />Standard Form.LLL (7/97) <br />