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Disclosure of Lobbying Activities <br />(Approved by OMB 0344 ®0046) <br />Complete this form to disclose lobbvine activities pursuant to 31 U.S.C. 1352 <br />I. Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />a. contract <br />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 />d. loan <br />For Material Change Only: <br />e. loan guarantee <br />f loan insurance <br />Year Quarter <br />Date Of Last Report: <br />4. Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />Address of Prime: <br />Prime <br />Subawardee Tier (if known) <br />Congressional District (if known) <br />Congressional District (if known) <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number (if applicable) <br />8. Federal Action Number (if known) <br />9. Award Amount (if known) $ <br />10. a. Name and Address of Lobbying Entity <br />b, Individuals Performing Services (including address if <br />(if individual, last name, first name, MI): <br />different from No. l0a.) (last name, first name, MI): <br />(attach Continuation Sheet(s) SF- LLL-A, ifnecessmy) <br />(attach Continuation Sheet(s) SF- LLL-A, 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 -time fee <br />C. commission <br />12. Form of Payment (check all that apply): <br />d. contingent fee <br />a. cash <br />e. deferred <br />b. In -kind; specify: Nature <br />f, other; specify: <br />Value <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) <br />contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF- LLL -A, ifnecessmy): <br />15. Continuation Sheet(s) SF -LLL -A attached: Yes No <br />16. Information requested through this form is authorized by title 31 <br />Signature: <br />U. S. C. section 1352. This disclosure of lobbying activities is a <br />material representation of fact upon which reliance was placed by <br />Print Name: <br />the tier above when this transaction was made or entered into. <br />This disclosure is required pursuant to 31 U. S. C. 1352. This <br />Title: <br />information will be reported to the Congress semi- annually and <br />will be available for public inspection. Any person who fails to <br />Telephone No: Date: <br />file the required disclosure shall be subject to a civil penalty of <br />not less than $10,000 and not more than $100,000 for each such <br />failure. <br />Federal Use Only <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Attachment number 4 <br />F -6 Page 106 <br />