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ATTACHMENT F <br /> Approved by OMB <br /> 0348-0046 <br /> DISCLOSURE OF LOBBYING ACTIVITIES <br /> Complete this form to disclose lobbying activities pursuant to 31 U. S .C. 1352 <br /> (See reverse for public burden disclosure.) <br /> 1 . Type of Federal Action : 2. Status of Federal Action : 3. Report Type: <br /> F] a. contract ❑ a. bid/offer/application a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative agreement c. post-award <br /> d. loan For Material Change Only : <br /> e. loan guarantee <br /> f. loan insurance year quarter <br /> date of last report <br /> 4. Name and Address of Reporting Entity : 5. If Reporting Entity in No. 4 is Subawardee, Enter Name <br /> and Address of Prime : <br /> ❑ Prime ❑ Subawardee <br /> Tier if known: <br /> Congressional District, if known: Congressional District, if known: <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description : <br /> CFDA Number, if applicable: <br /> 8. Federal Action Number, if known: 9. Award Amount, if known: <br /> 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if <br /> (if individual, last name, first name, MI) : differentfrom No. I0a) <br /> (last name, first name, Ml) : <br /> (attach Continuation Sheets) SF-LLLA, if necessary) <br /> 11 . Information requested through this form is authorized by title 31 U.S.C. Signature: <br /> section 1352. This disclosure of lobbying activities is a material <br /> representation of fact upon which reliance was placed by the tier above Print Name: <br /> when this transaction was made or entered into. This disclosure is required <br /> pursuant to 31 U.S.C. 1352. This information will be reported to Congress Title: <br /> semi-annually and will be available for public inspection. Any person who <br /> fails to file the required disclosure shall be subject to a civil penalty of not Telephone No. : Date : <br /> less than $10,000 and not more than $100,000 for each such failure. <br /> Federal Use Only: Authorized for Local Reproduction <br /> Standard Form - LLL (Rev 7 - 97) <br /> Form DEP 55-221 (01 /01 ) Page 1 of 2 <br /> DEP 55 -215 (01 /02) <br /> DEP Agreement No . GO 143 , Attachment F, Page 1 of 2 <br />