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Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />See reverse forub6c burden disclospureU <br />Type of Federal Action; Status of Federal Action: Report Type: <br />a. contract a. bid/offer/application a. initial filing <br />b. grant b. initial <br />award b. material change <br />c. cooperative agreement c. post -award <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />� <br />�° �°� " g Entity: <br />Name -an, Aeddress of Rspobrti <br />�awar ee ., Erste. <br />Reporting ty ' s 5ubawardee, Enter <br />Entity <br />dame <br />ardeeb <br />aping <br />of Prime: <br />Tier , if Known: <br />Congressional, if known:---Congressnal <br />, if known: <br />...w..�.n,. io.. .�_...._ _..... __._ ... �.-.,.,_ _w..w..... <br />..�, ��....w,..wu-. <br />Federal DepartmenntlAege�nc.y <br />�'. Federal Program Name/Description: <br />GFDA Number, if applicable: ...., . <br />�.,u a �e..�..._ ......,.. _...�. <br />w.,,�.�..._ .m,,.��.Y' <br />Federal Action Number, if known: <br />Awar..,.. .�owe_...._�......�.. �. eee....���.,..... .WW., <br />d Amount, if known: <br />of <br />services (including add <br />b. re <br />yrng M!).Registrant <br />(ifa. individual, last namesfirsf name <br />�;f differen'tdfrom Norf 10 )ung <br />(last name, first name, Ml). <br />11. Information requested through this form is <br />authorized by title 31 U.S.C. section 1352. This <br />Signature as w ... _ ,....., w............. <br />disclosure of lobbying activities is a material <br />representation of fact upon which reliance was placed by <br />Print Name: <br />the tier above when this transaction was made or entered <br />into. This disclosure Is required pursuant to 31 U.S.C. <br />itle: <br />1352. This Information will be reported to the Congress <br />semi-annually and will be available for public inspection. <br />1•elephone No.:Date: <br />,Any person who fails to file the required disclosure shall <br />be subject to a civil penalty of not less than $10,000 and <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 />