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l3iiddeir/IfResl oindeint <br /> Docusign Envelope ID:7208C774-7FB3-420E-A93E-5DE887787BB7 <br /> ooirmlplleied LJIJ%+LVJUr[C Vr LvaBYING ACTIVITIES Approved by OMB <br /> dooumeintwiiih Ilii$iid/ Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br /> Flirolposall (See reverse for public burden disclosure.) <br /> 1.Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> ❑a. contract ❑a. bid/offer/application ❑ 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. loan 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 /> ❑ Prime ❑ Subawardee and Address of Prime: <br /> Tier , if known <br /> Congressional District, if known: 4c Congressional 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 Registrant b. Individuals Performing Services (including address if <br /> (if individual, last name, first name, Ml): different from No. 10a) <br /> (last name, first name, Ml): <br /> 11,Information requested through this form is authorized by title 31 U.S.C. section Signature: <br /> 1352. This disclosure of lobbying activities is a material representation of fact <br /> upon which reliance was placed by the tier above when this transaction was made <br /> or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This Print Name: <br /> information will be available for public inspection. Any person who fails to file the <br /> required disclosure shall be subject to a civil penalty of not less than $10,000 and Title: <br /> not more than$100,000 for each such failure. <br /> Telephone No.:_ Date: <br /> Federal Use Only: Authorized for Local Reproduction <br /> Standard Form LLL(Rev.7-97) <br />