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Disclosure Of Lobbying Activities Contract Number 00027858 / Page 31 of 33 <br /> (Approved by OMB 0344 -0046) <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1362 <br /> 1. Type of Federal Action: 2 Status of Federal Action: 3 Report Type: <br /> ❑ a.. contract ❑ a, Bidlofferlapplication ❑ 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 <br /> ❑ Subawardee Tier (if known) <br /> Congressional District (f 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, Ml): different from No 10a ) (last name, first name, M0: <br /> (attach Continuation Sheets) SF-UL-A, if necessary) (attach Continuation Sheet(s) SF-UL-A, if necessary) <br /> 11. Amount of Payment (check all that apply): 13.. Type of Payment (check all that apply): <br /> $ actual planned ❑ a. retainer <br /> ❑ b one -time fee <br /> 12 Form of Payment (check all that apply): ❑ c commission <br /> ❑ d. contingent fee <br /> ❑ a cash ❑ e.. deferred <br /> ❑ b. In -kind; specify: Nature ❑ f. other, specify: <br /> Value <br /> 14 Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or <br /> Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheets) SF -LLL A, if necessary): <br /> 15. Continuation Sheet(s) SF -LLL -A attached: ❑ Yes ❑ No <br /> 16. Information requested through this form is authorized by Signature: <br /> title 31 U.. S. C section 1352. This disclosure of lobbying <br /> activities is a material representation of fact upon which Print Name: <br /> reliance was placed by the tier above when this transaction <br /> was made or entered into. This disclosure is required Title: <br /> pursuant to 31 U. S C. 1352 This information will be <br /> reported to the Congress semi - annually and will be Telephone No: Date: <br /> available for public inspection. Any person who fails to file <br /> the required disclosure shall be subject to a civil penalty of <br /> not less than $10,000 and not more than $100,000 for each <br /> such failure. <br /> Authorized for Local Reproduction <br /> Standard Form - LLL <br />