Approved by OMB No 0348-0046
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C 1352
(See Reverse for public burden disciosure }
1. Type of Federal Action:
a contract [| a, bid/offer/application
b grant b. initial award
€ cooperative agreement c. post-award
qd loan
€ loan guarantee
f oan insurance
2. Status of Federal Action:
3. Report Type:
[| a. initial filing
b. material change
For Material Change Only:
year quarter
date of last report
4. Name and Address of Reporting Entity:
[| Prime
Subawardee
Tier , if knowa
Congressional District, /f known:
§. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Congressional District, if known:
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number, if appticabie:
8. Federal Action Number, /f known:
9. Award Amount, /f known:
3
10. a. Name and Address of Lobbying Registrant
(# individual, last name, first name, Mi):
b. Individuals Performing Services (including address if
different from No, 10a)
(last name, first name, MI):
11, Information requested through this form is authorized by title 31 U.S.C.
section 1352 This disclosure of lobbying activities is a material
representation of fact upon which reliance was placed by the tier above
when this transaction was made or entered into. This disclosure is
required pursuant to 34 U.S.C. 1352. This information will be reported to
the Congress semi-annually and will be available for public inspection.
Any person who fails to file the required disclosure shail be subject to a
civil penaity of nol less (hai $10,000 and not more than $100,000 for
each such failure.
Signature:
Print Name
Title:
Telephone No.. Date.
Federal Use Only:
Authorized for Local Reproduction
Standard Form LLL (Rev 7-97)
