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<br /> DISCLOSURE OF LOBBYING ACTIVITIES <br /> Complete this form to disclose lobbying activities pursuant <br /> to 31 U.S.C. 1352 <br /> (See reverse for public burden disclosure) <br /> 1.Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> :=J a.contract D a.bid/offer/application 0 a. initial fit ing <br /> b.material change b.initial award b...terial change <br /> c.cooperative agreeøent 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 /> ----" <br /> 4.Name and Address of Reporting Entity 5.lf Reporting Entity in No.4 is Subawardee, <br /> 0 Prime 0 Subawardee Enter Naøe and address of Prime: <br /> Tier . if known <br /> Conar.""inruol A.'.. '.. if known: Congressional District, if known: <br /> <br /> 6.Federal Depertment/Agency: 7. Feøeral 'Program Name/Descrìptlon: <br /> --- CFDA No., if applicable <br /> 8.federal Action No., if known: 9.Award Amount, if known: <br /> $ <br /> 10.a. Name and Address of Lobbying Entity b.lndividuals Performing Services-(including <br /> if individual, last name, first name, NI): address if different from No. <br /> first name, NI): <br /> 11.Amount of Payment(check all that apply): 13.Type of Payment (check all that apply): <br /> $ actual plamed a.retainer <br /> b.one-time fee <br /> 12.Form of Payment (check all that apply): c .cOllJlli ss ion <br /> a.cash d.contingent fee <br /> b.in-kind:specify: nature e.deferred <br /> value f.other:specify <br /> ----I <br /> Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or <br /> Nember(s) contacted, for Payment Indicated in Item 11: <br /> 1'LContinuation Sheet(s) Sf-LLL-A attached: t:lYes ONo <br /> 16.1nformation requested through this form is authorized by title 31 U.S.C. <br /> Section 1352. This disclosure of lobbying 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 Name: <br /> pursuant to 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 Title: <br /> who fails to file the required disclosure shall be subject to 8 civil penalty <br /> of not less than $10,000 and not more than $100,000 for each such failure. Date: <br /> Telephone No.: <br /> <br /> federal Use Only: Standard Form-lll <br />