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DISCLOSURE OF LOBBYING ACTIVITIES IV/A Approved by OMB <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 osas-Does <br /> See reverse for ublic burden disclosure. <br /> Type of Federal Action: ` ' 2. Status of Federal Action: 3. Report Type: <br /> a. contract aa. bid/offer/application o a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement ~ c. post-award For Material Change Only: <br /> d. loan ~ .year quarter <br /> e. loan guarantee ~ date of last report <br /> f. loan insurance <br /> 4. Name grid Address o eporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee; Enter Name <br /> .Q Prime ? sub and Address of Prime: <br /> Tier if known <br /> Con ressionai District, if known: Con ressional District, if known: <br /> <br /> . 6. Federal Department/Agency: 7. Federal Program NameJDescription: <br /> . ~ CFDA Number, if applicable: . <br /> 8. Federal Action Number; if known: 9. and Amount, if known: <br /> $ • <br /> 10. a. Name and Address of Lobbying Entity b. Indivi als Performing Services (including address if <br /> (if individual, lastnarne, first name, MI): differen rom No. ~Oa) - - - <br /> _ (last-narn -first-narne,-Ml-): - <br /> attach Continuation Sheets SF-LLLA, ifnecessa ) <br /> 91. Amount of Payment (check all #Mat aPplY); 13: Type of Payment ( +eck all that apply). <br /> actual ? planned a. retainer <br /> b. one-time fee <br /> 42. form of-Payment-(check all-that apply): - ? c commission - • - <br /> ? a. cash ~ ? d. contingent tee <br /> ? b in-kind;specify: rlatuY~ - _._w.___ _.Q e.deferred <br /> aloe _ ~fhe~; <br /> 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, incl ing officer(s), <br /> employee(s), or Member(s) contacted, for Payment Indicated in Item 1.1: <br /> (attach Continuation Sheet(s) SF-LLLA, if necessary) <br /> 15. Continuation Sheets SF-LLLA attached: ? Yes ? No <br /> 16. lnfortnation requested through this forth as at,titor;Zed by title 31 U.S.C. section Signature: <br /> 1352. This dscbsure a lobbying activities is a material representation a fact <br /> upon which reliance was placed by the tier above when this transaction rues made <br /> a entered ff110. This discbwre b required pursuant ro 31 U.S.C. 1352. This Print Name: <br /> infomtation wiN be reported to the Congress semi-annually and will. be available for <br /> pudic inspection. My person who fails ro file the required disclosure shah be Title: <br /> subject ro a civil penalty a na less that stoooo and na more than stoo,ooo for . <br /> eat:ha,a~faNt,re. Telephone No.: Date: <br /> t" ~ ; • Authorized for Local Reproduction <br /> ~ rr.. ~~r ~ c <br /> Federal {lse~~jnt~'.~,_• . , <br /> r.~ • .i = ~•a+ ..r~•~ Standard Form LLL(Rev. 7-9 <br /> N2 <br /> _ _ <br /> <br />