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Consolidated Agreement FYI <br />Disclosure of Lobbying Activities <br />(Approved by OMB 034841046) <br />Comnlete this form to disclose lobbying activities nursuant to 31 U.S.C. 1352 <br />Page 33 of 33 <br />1. <br />Type of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />❑ <br />a. contract <br />❑ a. Bid/offer/application <br />❑ a. initial filing <br />❑ <br />b. grant <br />❑ b. Initial Award <br />❑ b. material change <br />❑ <br />c. cooperative agreement <br />❑ c. Post -Award <br />❑ <br />d. loan <br />For Material Change Only: <br />❑ <br />e. ban guarantee <br />❑ <br />f. loan insurance <br />Year Quarter <br />Date of Last Report: <br />4. <br />Name and Address of Reporting Entity: <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name <br />❑ <br />Prime <br />and Address of Prime: <br />❑ <br />Subawardee Tier , (if known) <br />Congressional District d known <br />Congressional District if known <br />6. <br />Federal DepartmentlAgency: <br />7. Federal Program Name/Description: <br />CFDA Number (if applicable) <br />8. <br />Federal Action Number (if known) <br />9. Award Amount (if known) : <br />10. a. Name and Address of Lobbying Registrant <br />b. Individuals Performing Services (including address if <br />(ff individual, last name, first name, MQ: <br />different from No. 10a.) (last name, first name, MO: <br />attach Continuation Sheets SF4 A /f necessary) <br />attach Continuation Shee s SF -LLL -A, if necessary) <br />11. <br />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 />❑ <br />a. cash <br />❑ e. deferred <br />❑ <br />b. In-kind; specify: Nature <br />❑ f. other; specify: <br />Value <br />14. <br />Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or <br />Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheet(s) SF -LLL -A, if necessary): <br />15. <br />Continuation Sheet(s) SF -LLL -A attached: <br />❑ Yes ❑ No <br />16. <br />Information requested through this form is authorized by <br />Signature: <br />title 31 U. S. C. section 1352. This disclosure of lobbying <br />activities is a material representation of fact upon which <br />reliance was placed by the tier above when this transaction <br />Print Name: <br />was made or entered into. This disclosure is required <br />pursuant to 31 U. S. C. 1352. This information will be <br />Title: <br />reported to the Congress semi-annually and will be <br />available for public inspection. Any person who fails to file <br />Telephone No: Date: <br />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 <br />such failure. <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Public reporting burden for this eoHection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing <br />data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate <br />or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction <br />Project (0349-00461 Washington, D. C. 20503 <br />