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Approved by OMB Disclosure of Lobbying Activities Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 reverse for public burden 0348-0046 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 c. post -award d. loan For material change only: e. loan guarantee Year quarter f. loan insurance Date of last report 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Piirne Subawardee Name and Address of Prime: Tier , if Known: Congressional District, if known: 6. Federal Department/Agency: 8. Federal Action Number, iflrnown: 10. a. Name and Address of Lobbying Registrant (:f individual, last name, first name, MI): Congressional District, if known: 7. Federal Program Name/Description: CFDA Number, if applicable: 9. Award Amount, if known: b. Individuals Performing Services (including address if dierentfrom No. I0a) (last name, first name, MI): 11. Information requested through this form is authorized by title 31 U.S.C. section 1352. This Signature ) disclosure of lobbying activities is a material representation of fact upon which reliance was placed Print Name: �nnitr by the tier above when this transaction was made or into. This disclosure is �� J� •r-� r entered required pursuant to 31 Title:U.S.C. 1352. This information will be reported to the --7 Congress semi-annually and will be available for public Telephone Not D,*5 c1y� l q a - 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 (Rev. 7-97)