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<br />DISCLOSURE OF LOBBYING ACTIVITIES <br />-~-.....-. <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />Approved by OMB <br />0348-0046 <br /> <br /> (See reverse for Dublic burden disclosure.) <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: I <br />D a. contract Da. bid/offer/application D 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 />o Prime o Subawardee and Address of Prime: <br /> Tier I If known: <br />Congressional District, If known: ConQresslonal District, If known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number,'lf app/icable:' . <br />8. Federal Action Number, If known: 9. Award Amount, if known: <br /> $ <br />10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br />(ifindividual, last name, first name, M/): different from No. 10a) <br /> (last name, first name, M/): <br /> (attach Continuation Sheet(s) SF-LLLA. if necessary) <br />11. Amount of Payment (check ai/ that apply): 13. Type of Payment (check all that apply): <br />$ o actual o planned o a. retainer <br /> o b. one-time fee <br />12. Form of Payment (check all that apply): o c. commIssIon <br />D a. cash D d. contingent fee <br />o b. In-kInd; specify: nature o e. deferred <br /> value o f. other; specify: <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Service, Including offlcer(s), <br />employee(s), or Member(s) contacted, for Payment Indicated In It~m 11: <br /> (attach ConUnuation Sheet(s) SF-LLLA. if necessary) <br />15. Continuation Sheet(sl SF-LLLA attached: DYes DNo <br />16 1nI0000000Uon requested IIvough INs fonn Is authorized by uUe 31 U.S.C. section Signature: <br />. 1352. ThIs dlsdosunl 01 lobbying activities Is a materiel representallon oIlact <br />upon whIc:h ,.aance was p'-d by the tier above when INs lranHcUon was made Print Name: <br />or ante*, Into. ThIs dIsdosIn Is rwquIred pursuant to 31 U.S.c. 1352. ThIs <br />InlOllTlolUon wlI be reported to !he Congress Mml-ennuelly and wlI be avaUable for Title: <br />public Inspection. Any....-. who '''' to lIle the requInMI disclosure wi be <br />aubjecl to a dvI penefly of not less that $10,000 and not more than $100.000 tor Telephone No.: Date: <br />each auc:h tarura. <br /> .. I Authorized for Local Reproducllon <br />Federal Use Only: Standard Form LLL (Rev. 7-97) <br /> <br />, <br />" <br />