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Complete this form to disclose lobbying activities <br />(See instructions for public burden disclosure) <br />1. Type of Action: <br />2. Status of Action: <br />3. Report Type: <br />❑ a. contract <br />❑ a. bid/offer/application <br />❑ a. initial filing <br />❑ b. grant <br />❑ b. initial award <br />❑ b. material charge <br />❑ c. cooperative agreement <br />❑ c. post -award <br />❑ d. loan <br />For Material Change Only: <br />❑ e. loan guarantee <br />year quarter <br />❑ f. loan insurance <br />date of last report <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />❑ Prime ❑ Tier if known <br />Address of Prime: <br />6. Department Agency: <br />7. Program Name/Description: <br />8. Action Number, if known: <br />9. Award Amount, if known: <br />10. a. Name and Address of Lobbying Entity <br />b. Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): <br />different from No. 10a) <br />(last name, first name, Ml): <br />(attach Continuation Sheet(s) SF -LLL -A, if necessary <br />11. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply): <br />❑ a. retainer <br />$ ❑ actual ❑ planned <br />❑ b. one-time fee <br />❑ c. commission <br />❑ d. contingent fee <br />12. Form of payment (check all that apply): <br />❑ a. cash <br />❑ e. deferred <br />❑ b. in-kind specify: nature <br />❑ f. other; specify: <br />value <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service including officer(s), employee(s), or Member(s) <br />contacted, for Payment indicated in Item 11: <br />(attach Continuation Sheet(s) SF -LLL -A, if necessary) <br />15. Continuation sheet(s) SF -LLL -A attached: Yes <br />❑ No <br />16. This disclosure of lobbying activities is a material <br />representation of fact upon which reliance was placed by the <br />tier above when this transaction was made or entered into. <br />Signature: <br />This information will be available for public inspection. <br />Print Name: <br />Title: <br />Telephone: <br />Date: <br />KTB Use Only: <br />Authorized for Local Reproduction Standard Form - LLL <br />INSTRUCTIONS FOR COMPLETION OF SF -LLL (STANDARD FORM —LLL) <br />Memorandum of Understanding Page 2 <br />