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<br /> N A ,¡lA <br /> DISCLOSURE OF LOBBYING ACTIVITIES <br /> Complete this form to disclose lcbOying activities pursuant <br /> to 31 U.S.C. 1352 <br /> (See reverse for public burden disclosure) <br /> 1. Type of Federal Act i on: 2. Status of Federal Action: 3. Repon Typoe: <br /> ] a.contract D a.bid/offer/application 0 IJ.initial filing <br /> b.material ch~e b.initial award b.material chðOge <br /> c.cooperative aijreement c.post'award For Haterial Change Only: <br /> d.loan year c¡uaner <br /> e.loan guarantee date of last report <br /> f.loan insurance <br /> - <br /> ame and Address of Reporting Entity 5.Ii Reporting Entity in No.4 is Subawardee, <br /> ' Prime 0 Subawardee Enter Name and address of Prime: <br /> Tier. if Known <br /> Conc¡ressional Oistr'ct if known: Congressional District, if known: <br /> 6.FederalDepartment/Aijency: (.¡.eaeral .Program Uame/Descrïpt I on: <br /> CFDA No., if applicable <br /> a.Federal Action No., i f kr1Olo«1: 9 .Award Amoc.nt, if known: <br /> S <br /> 10.a. Hame and Address of Lobbying Entity b.{ndividuals Performing Services <incLuding <br /> if individual. last name, first name, HI): address if different from Ho. <br /> first name, HI): <br /> ~ <br /> It.Amount of Payment(ched: alL that apply): 13. Type of Payment (cheer. al L that apply): <br /> S actual p l a tY')e<j a.retainer <br /> b.~.time fee <br /> t2.Form of Payment (cheer. all that apply): c.comnission <br /> a.cash d.contingent fee <br /> b. in'r.ind:specify: Mture e.deferred <br /> value f.other:specify <br /> <br /> .' Brief Description of Services Performed or to be Performed and Date(s) of Service, incLuding officer(s), ~loyee(s), or <br /> ~cnt)er(s) contacted. for Payment Indicated in {tern 11: <br /> , <br /> 15.ContiraJ4tion Sheet(s) SF-LLL'A attached: DYes ONo <br /> 16. Informacion r~sted through this form is authorized by title 31 U.S.C. <br /> Section 1352. This disclosure of loCOying activities is a material Signature: <br /> representation of fact upon which reliance was placed by the tier above when <br /> thIs transaction was made or entered into. This disclosure is required Print Hame: <br /> purSlJant co 31 U.S.C. 1352. This information will be reported to the <br /> Congress semi-annually and will be available for public inspection. Any person Tit le: <br /> who fails to file the r~ired disclosure shall be subject Co a civil penalty <br /> of not less th~ $10,000 and not more than S100.000 for each such failure. Date: <br /> Telepnone Ho.: <br /> Federal Use Only: Standard Form-LLL <br />