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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 ❑ a. Bid /offer /application ❑ a. initial filing ❑ b. grant ❑ b. Initial Award ❑ b. material change ❑ c. cooperative agreement ❑ G. Post -Award El d. loan For Material Change Only: ❑ e. loan guarantee ❑ t, 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 ❑ 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, MO: different from No. IOa.) (last name, first name, MO: (attach Continuation Sheet(s) SF- LLL -A, ifnecessary) (attach Continuation Sheet(s) SF- LLL -A, ifnecessary) 11, Amount of Payment (check all that apply): 13, Type of Payment (check all that apply): $ actual planned ❑ a. retainer ❑ ❑ b. one -time fee c. commission 12. Form of Payment (check alt that apply): ❑ d, contingent fee ® a. cash ❑ e. deferred ❑ b. In- kind; specify: Nature d 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 I1(attach Continuation Sheet(s) SFLLL -A, if necessary): 1 15, Continuation Sheet(s) SF -LLL -A attached: ❑ Yes ❑ No 16. Information requested through this form is authorized by title 31 U. S. C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. This disclosure is required pursuant to 31 U. S. C. 1352 This information will be reported to the Congress semi - annually and will be 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 Signature: Print Name: Title: Telephone No: Date: Authorized for Local Reproduction Standard Form - LLL Attachment number 1 F -13 Page 287