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Approved by OMB <br />034$-0046 <br />Disclosure of Lobbying Activities <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />rn__ 4r-....1.1:.. 1.u.Aon flierlnmirP~ <br />JVV 1 <br />1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br />a. contract a. bid/offer/application a. initial filing <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post-awazd <br />d. loan <br />e. loan guarantee <br />f. loan insurance <br />4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter <br />Prime Subawardee Name and Address of Prime: <br />Tier , if Known: <br />Con resslonal District, if lnown: Con ressional District if known: <br />6. Federal Department/Agency: <br />7. Federal Program Name/Deacription: <br />CFDA Number, if applicable: <br />7. Federal Action Number, if known: <br />9. Award Amount, if known: <br />S <br />10. s. Name and Address of Lobbyiag Registrant <br />b. Individuals Performing Services (including address if <br />(if individual, lasi name, first name, MI): <br />di`'erent from No. l0a) <br />(last name, first name, MI): <br />11. Informatlon requested t6rough this form is suthorized by <br />title 31 U.S.C. section 1352. This disclosure of lobbying <br />Signature: <br />activities is a material represeatation of fact apon whic6 <br />relisnce was placed by the Ner above when this transaction <br />print Name: <br />was made or entercd into. This disclosure is required <br />pursaant to 31 U.S.C.1352. T6ia informstion will be reported <br />Title: <br />to the Congresa semi-annually and will be available for public <br />inspection. Any persoa who fails to file t6e required <br />Telephone No.' Date• <br />disclosure shall be subject to r civil penalty of not less than <br />$10 000 and not more than $100 000 for each suc6 failure. <br />Federal Use Qnly <br />Aut6orized for Local Reproduction <br />Stsndard Form - LLL (Rev. 7-97) <br />28 <br />