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ATTACHMENT F Approved by ONIR <br />0348-0046 <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete <br />this <br />form to <br />disclose lobbying <br />activities pursuant to <br />31 <br />U.S.C. <br />1352 <br />(See <br />reverse for public <br />burden dISClesan0.) <br />b. grant <br />b. initial award <br />1. <br />TN pe of Federal Action: <br />2. Status of Federal Action: <br />3. Report Type: <br />Ela. <br />contract <br />a. bid/offer/application <br />a. initial filing <br />b. grant <br />b. initial award <br />h. material change <br />c. cooperative agrtement <br />d. loan <br />c. post -award <br />For Material Change Only: <br />e. loan guarantee <br />f loan insurance <br />year quarter <br />date of last report <br />4. <br />Name and Address of Reporting Entity: <br />5. If Reporting Entity in No.4 is Subawardee, Enter Name <br />El ElSubawardee <br />and Address of Prime <br />prime <br />Tier if known: <br />Congressional District, if known: <br />Congressional District, if known. <br />6. <br />Federal Department/Agency: <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable. <br />8. <br />Federal Action Number, fknonn <br />9. Award Amount, ifknown' <br />10. <br />a. Name and Address of Lobbying Entity <br />b. Individuals Performing Services (including address if <br />(f individual. Inst mmne, firs! name, Ml): <br />different from No. 10a) <br />(last name. first name, Ml): <br />(affnch Confinuafion Sheets) <br />Sl--LLLA, if necaysm}J <br />I1. <br />Inl'nrma[ion requested through this luno is authorized by tide 31 U.S.C. <br />Signature <br />section 1352. This disclosure of lobbving activities is a material <br />representation of fact upon which reliance was placed by the tier above <br />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 <br />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 chit pen al is of not <br />Telephone No.: Dale: <br />less than Sl 0,000 and not more than 5100,000 for each such failure. <br />Federal Use Only: <br />Authorized for Local Reproduction <br />Standard Form—LLL (Rcv7-97) <br />Form DEP 55-221 (01/01) <br />DEP Agreement No. G0182, Attachment F, Page 1 of 2 <br />