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j3lid deislpcndent. <br />Docusign Envelope ID: E74COCFE-CO64-4OD2-A75B-E107999569F8 <br />completed DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br />docu i ment. wiitlin I13iid/ <br />lnroposell. Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br />See reverse for public burden disclosure. <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />Ll a. contract <br />la. bid/offer/application <br />1 a. initial filing <br />b. grant <br />ub. initial award <br />a b. material change <br />c. cooperative agreement <br />c. post -award <br />For Material Change Only: <br />d.loan <br />year quarter <br />e. loan guarantee <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />❑ Prime ❑ Subawardee <br />and Address of Prime: <br />Tier , if known: <br />Congressional District, if known: 4c <br />Congressional District, if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable: <br />8. Federal Action Number, if known: <br />9. Award Amount, if known: <br />10. a. Name and Address of Lobbying Registrant <br />b. Individuals Performing Services (including address if <br />(if individual, last name, first name, Ml ): <br />different from No. 10a ) <br />( last name, first name, Ml ): <br />11Information requested through this form is authorized by title 31 U.S.C. section <br />.1352. <br />Signature: <br />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 />Print Name: <br />or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This <br />information will be available for public inspection. Any person who fails to file the <br />Title: <br />required disclosure shall be subject to a civil penalty of not less than $10,000 and <br />Telephone No.: Date: <br />not more than $100,000 for each such failure. <br />Federal Use Only: <br />Authorized for Local Reproduction <br />Standard Form LLL (Rev. 7-97) <br />Page 33 of 43 <br />