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Disclosure Of Lobbying Activities (Approved by OMB 0344-0046) Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: ❑ a. contract 0 a. Bid/offer/application 0 a. initial filing ❑ b. grant 0 b. Initial Award ❑ b. material change 0 c. cooperative agreement 0 c. Post-Award ❑ d. loan For Material Change Only: ❑ e. loan guarantee ❑ f. loan insurance Year Quarter Date Of Last Report: 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime: ❑ Prime 0 Subawardee Tier (if known) Congressional District(if known) Congressional District(if known) 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number(if applicable) 8. Federal Action Number(if known) 9. Award Amount(if known)$ 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services(including address if (if individual,last name, first name, MI): different from No. 10a.) (last name, first name, Ml): (attach Continuation Sheet(s)SF-LLL-A,if necessary) (attach Continuation Sheet(s)SF-LLL-A,if necessary) 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): $ actual planned 0 a. retainer ❑ b. one-time fee 12. Form of Payment(check all that apply): ❑ c. commission ❑ d. contingent fee ❑ a. cash ❑ e. deferred ❑ b. In-kind;specify: Nature ❑ f. other; specify: Value 14. Brief Description of Services Performed or to be Performed and Date(s)of Services, including officer(s),employee(s), or Member(s)contacted,for Payment Indicated in Item 11(attach Continuation Sheet(s)SF-LLL-A,if necessary): 15. Continuation Sheet(s)SF-LLL-A attached: ❑ Yes ❑ No 16. Information requested through this form is authorized by Signature: title 31 U.S. C.section 1352. This disclosure of lobbying activities is a material representation of fact upon which Print Name: reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required Title: pursuant to 31 U. S. C. 1352. This information will be reported to the Congress semi-annually and will be Telephone No: Date: available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than$10,000 and not more than$100,000 for each such failure. Federal Use Only Authorized for Local Reproduction Standard Form-LLL