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DISCLOSURE OF LOBBYING_ACTIVITIES ApprovedbyOMB <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 osaaooas <br />(See reverse for pubiic burden disclosure.) <br />1. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: t <br />❑ a. contract <br />F-I a. bid/offer/application <br />~ a. initial filing <br />b. grant <br />b. Initial award <br />b. material change <br />c. cooperative agreement <br />c. post-award <br />For Materiai Change Only: <br />d.loan <br />year quarter <br />e. loan guarantee ' <br />date of last report <br />f. loan insurance <br />4. Name and Address of Reporting Entity: <br />S. If Reporting Entity In No. 4 Is a Subawardee, Enter Name <br />❑ Prime ❑ Subawardee <br />and Address of Prime: <br />Tier , Ifknown: <br />Con resslonal District, ifknown: <br />Con ressional District, ifknown: <br />6. Federal DepartmenUAgency: <br />7. Federal Progrem NamelDescriptlon: <br />CFDANumber, ifapplicable:- <br />8. Federal Action Number, i(known: <br />9. Award Amount, ifknown: <br />$ <br />10. a. Name and Address of Lobbying Entity <br />b. Individuals Performing Services (including address if <br />(ifindividual, last name, first name, MI): <br />different irom No. 10a) <br />(last name, firstname, MI): <br />(attach ContinuaUOn Shee <br />t(s) SFLLLA, if necessary) <br />11. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply): <br />$ ❑ actual ❑ planned <br />❑ a. retainer - <br />❑ b. one-tima tea <br />12. Form of Payment (check all that apply): <br />❑ e. commisston <br />❑ a. eash <br />❑ d. contingent fea <br />~ b. In-kind; spaeity: f18tUf0 <br />❑ e. deferrad . <br />V81UB <br />❑ t. other, speclfy: <br />14. Brief Descrlptipn of Servlces Pertormed or to be Performed and Date(s) of Service, including offlcer(s), <br />employee(s), or Mem6er(s) contacted, for Payment Indicated In Item 11: <br />(attach ConPnuaNon Sheef s SFLLUI, flnecessa ) <br />15. Contlnuatlon Sheet s SF-LLLA attached: ❑ Yea ❑ No <br />'"~m"'.a"°"° °.ow"'"' a""".""°"`°° er au. a, ua.e...cSon <br />16 <br />Slgnature: <br />. <br />1352. fi4 Ebtlaun N bb0y1^Y MMUea ba mleAY rapra+onUtlm M hc4 <br />'w°"`"'uc""""'""0'°°bi"""".°°"°""'°"'"'°'""`"°'"'°°'"'°° <br />PrintName: <br />«.wf.a Nm n+i m.ao... ro~.aww w~•~•m m ai us.a 1uz mi. <br />infamutlon M M nporlM b IM Caqnss Smii•rmuetly rk wM M MBo6N br <br />ww a.awW. .na w <br />ro aw a m. u,. r <br />Tltle: <br />pAft wpeaw. Nn n«sw <br />w <br />wel.u e. a+ wrMr afa w. nn $+o.ooo w mt ~ em $+oo.ooo ror <br />tl <br />m <br />w <br />Telephone No.: Date: <br /> <br /> <br />, „ <br />, <br />- <br />Authorized for lacal Reproduction <br />F6defdl U38 Ot11J/: . . ~ . <br />Standard Form LLL Rev.7•97 <br />