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40 0 Disclosure of Lobbying Activities Approved by OMB 03,18.0c." Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 - (See reverse side for Instructions.) the me for reviewing Public` Reporting Burden for this collection of ma n awning the data estimated average and completingreand rev ewingethe colllection of information. Send comcmens; searching existing data sources, gathering g suggestions for reducing this burden, to the Office of Managemenr regarding this burden estimate or any other aspect of this collection of information, includin sugg and Budget. Paperwork Reduction Project (094"046), Washington, D.C. 20503. i 3 Report Type: 1. Type of Federal Action: 2. Status of Federal Act a, initial filing a. contract a. bZottedapplication b, material change b. grant ❑ b. initial award N/ A c. post -award For Material Change Onl� / A c. cooperativeagreemenl/A Po year quarter d. loan date of last repo e. loan guarantee report �---- .re _ .'a . anrt Address of 9. Award Amount, if known: 6. Federal Action Number, if known: $ N/A N/A b. Individualaperforming Services (indueingaddressitdifferent from Nc '�_ first name. MI):10a. Name and Address of Lobbying Registrant (last name, (if individual, last name, first name. MI): N/A _------ 11. Information requested through this form is authorized by Sec. 3119 Pub. L.101.121,103 Stat. 750, Th amended lsure of lobby ng activities 65, Stat. 700 (31 U.S.C. 1352). which reliance was placed is a material representation of fact upon by the 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 rson who fails to fsemiannually and ileilthe requirel be d for public inspection. Any p disclosure shall be subject to a civil penalty of not less than 510,000 and not more than S100,0001or each such failure. Fndor,d Uc^ Only: _ N/A Signature: Print Name: _—x�- CHAIRMAN Title: (j'(p/)5C7 - YO CO Date: �- TelephoneNo.___ Authorized for local Reproaucn Stand,,d Form -U L 0 5. if Reporting Entity in NO- 413 4. Name and Address of Reporting Entity: Prime 7 Subawardee Tier ;t known: Prime: I N/A N; A i Congressional District, it known: congressional District, it known: 7. Federal Program Name/Descriptlon: I 6. Federal Department/Agency: N/A N/A CFDA Number. it applicable: 9. Award Amount, if known: 6. Federal Action Number, if known: $ N/A N/A b. Individualaperforming Services (indueingaddressitdifferent from Nc '�_ first name. MI):10a. Name and Address of Lobbying Registrant (last name, (if individual, last name, first name. MI): N/A _------ 11. Information requested through this form is authorized by Sec. 3119 Pub. L.101.121,103 Stat. 750, Th amended lsure of lobby ng activities 65, Stat. 700 (31 U.S.C. 1352). which reliance was placed is a material representation of fact upon by the 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 rson who fails to fsemiannually and ileilthe requirel be d for public inspection. Any p disclosure shall be subject to a civil penalty of not less than 510,000 and not more than S100,0001or each such failure. Fndor,d Uc^ Only: _ N/A Signature: Print Name: _—x�- CHAIRMAN Title: (j'(p/)5C7 - YO CO Date: �- TelephoneNo.___ Authorized for local Reproaucn Stand,,d Form -U L 0