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<br />- <br /> <br />....... <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMB <br />0346-0046 <br /> <br /> 'See reverse for Dublic burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />D a. contract D a. bid/offer/application D 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 quarter ____ <br />e. ioan guarantee date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is a Subawardee, Enter Name <br />o Prime o Subewardee and Address of Prime: <br />Tier ____, ifknown: <br />Conaressional District, if known: Conaressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number, If applicable: <br />8. Federal Action Number, If known: 9. Award Amount, If known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(if individual, last name, first name, M/): different from No. 10a) <br /> (last name, first name, MI): <br /> (attach ContinuaUon Shee~s) SF-LLLA. If necessary) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply): <br />$ ------ o acluel o planned o a. retainer <br /> o b. one-time fee <br />12. Form of Payment (check all that apply): o c. commission <br />o a. cash o d. contingent fee <br />o b. in-kind: specify: nature _____ o e. defarred <br /> value --- o f. other, specify: <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 /> (attach ContinuaUon Shaet(s) SF-LLLA, If naoessary) <br />15. Continuation Sheet/s) SF.LLLA attached: DYe. DNa <br />16 Information requested through this fonn Is authorimd by tiUe 31 U.$.C. seellon Signature: <br />. 1352. This dlsdosure of lobbying IIICIMties is 8 malerlal representation of fact <br />upon which reliance was placed by the tier above when this transaction was made Print Name: <br />or entered Into. This dlsdosure is requlrad punluanllo 31 U.S.C. 1352. This <br />Informatioo will be reported to the Congess semJ..annualy and will be ayallllble for Tille: <br />pubic Inupectlm. lvIy parson who fails to file the required dlldosul'8 shall be <br />subject to a civO penalty of not les8 thai $1Q,OOO and not more than $100,000 for Telephone No.: Date: <br />each such failure. <br />'. . .. ". ." .... ....... :., Authorized for Local Reproduction <br />Federal Use Only: ... . . .' ..... .. ... Standerd Form LLL (Rev. 7-97) <br />