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DISCLOSURE OF LOBBYING ACTIVITIES <br />COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVIT117S PURSUANT TO 31 U.S.C. 1352 <br />1. Type of Federal Action; 2. Status of Federal Action: 3. Report Type: <br />Ma. contract =a. bid/offer/application a. initial <br />b. grant b. initial award b. material cha/only, <br />c. cooperative agreement e. post -award <br />d. loan For Material Ch . <br />c. loan guarantee year quarter <br />f. loan insurance date of I report <br />4. Nance and Address of Reporting Entity 5. If Reporting Entity in No. 4 K Sub awardee, <br />Enter Name and Address Prime: <br />Prime Subawardee <br />Tier—, if known <br />Congressional District, if known Congressiona istrict, if known <br />6. Federal Department/Agency: 7. Federal Pr ram Name[Description: <br />CFD umber, it applieablo <br />8. Federal Action Number, if known: 9. Ai rd Amount, if known: <br />10. a. Name and Address of Isobby Entity b, Individuals Performing Services (including <br />(If individual, last name, first name, MI) address if different from No, 10a) <br />(last name, first name, MI) <br />(attach Crl <br />nuation Sheet(s) if necessary) <br />1I. Amount of Payment (check all that ap 13. 'type of Payment (check all that apply) <br />$ ® actual lanned a. retainer <br />b, one-time fee <br />12. Form of Payment (check all tha apply): c. commission <br />ea. cash d. contingent fee <br />b. in-kind; specify: lure e deferred <br />value £other, specify <br />14. Brief Description of Ser ices Performed or to be performed and Date(s) of Service, including <br />officer(s), employce(s)� r mcmber(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Shect(s) if necessary) <br />15. Continuatio Sheet(s) attached. Yes No <br />16. Information ruestod through this form is authorized by a <br />Title 31 US.,action 1352. This disclosure of lobbying Signature:— <br />reliance waWplaccd by the tier above when his transaction1/ '7 <br />was made or entered into. This disclosure is required Print Name: G1 Ltl ✓ . <br />pursuant to 31 U.S.C. 1352. This information will be <br />reported to Congress semiannually and will be available for <br />public inspection. Any person who fails to file the required Title: _j <br />disclosure shall be subject to a civil penalty of not less than q ` �y <br />$10,000 and not more than $100,000 for each such failure. Telephone No.: 6 �� 7%-7 U Date: /t// <br />Authorized for Local Reprodueti <br />Federal Use Only: Standard Form - LLL <br />Stmidard Form LLL Rov. 09-12-97 <br />