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<br />'-" <br />Disclosure of Lobbying Activities <br /> <br />"> ~~. .,v,,~~.. . _, ~~_~ ~~ <br /> <br />.;::;"~'~~~Q1~~~~~~! <br /> <br />Approved by OMB 0348-<l046 <br /> <br />Complete this tonn to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse side for Instructions and P~ic Reporting burden statement) <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.lnitial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement e. post-award For Material Change Only <br /> d. loan year (my) quarter <br /> e. loan guarantee <br /> f. loan insurance date of last repcrt ("!"'dd!yyyy)_____ <br />.. . ., If Reporting Entity In No. 4 Is Subawardee. enter Name and Address <br />Name and Address of Reporting Entity 5. <br /> DPrime D Subawardee Tier . if known: of Prime <br /> Congressional District. if known Congressional District, if known <br />6. FederalOeparbnenUAgency 7. Federal Program Name/Description <br /> - <br /> CFDA Number, Wapplicable <br />8. Federal Action Number, if known 9. Award Amoun~ W known <br /> $ <br />10a. Name and Address of Lobbying Registrant b. Individuals Perfonning Services (including address if different from No. lOa.) <br /> (if individual, last name, first name, MI) (last name, first name, Ml) <br /> <br />(attach continuation sheet(s) if necessary) <br />13. Type of Payment (check an that apply) <br /> <br />o a. retainer <br /> <br />D b. one-time fee <br /> <br />D c. commission <br /> <br />D d. contingent fee <br /> <br />o e. deferred <br /> <br />o f. other (specify) <br /> <br />planned <br /> <br />11. AmountofPayment(checkaDlhatappfy) <br />$ actual <br />12. Form of Payment (check. aft that apply) <br />D a. cash <br />o b. in-kind; specify: nalure <br />value <br /> <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s). or Member(s) contacted, <br />for Payment Indicated in Item 11 <br /> <br />(attach oontlnuation sheet's) if necessary) <br /> <br />15. Continuation sheets attached DYes D No <br /> <br />16.lnfonnation requested through this form is authorized by See.319, <br />Pub. L. 101-121, 103 Stat. 750, as amended by sec. 10; Pub. L. 104- Signalure <br />65, Stat. 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 into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. This Infonnation Title <br />will be reported 10 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. <br /> <br />Federal1Jse,COnly:. . <br /> <br /> <br /> <br />Authorized for Local Reproduction <br />Standard Form-LLL (7/97) <br />