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Disclosure offk. 11YA- ihe(tOW36254, Amendment Number 2 / Page 15 of 17 <br />(Approved by OMB 0348 -0046) <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.G. 1352 <br />1 Type of Federal Action* <br />2 Status of Federal Action, <br />3. Report Type: <br />❑ a. contract <br />❑ a Bid /offer /application <br />❑ a, initial filing <br />❑ b. grant <br />❑ b. Initial Award <br />❑ b. material change <br />❑ c cooperative agreement <br />❑ c Post -Award <br />❑ d. loan <br />For Material Change Only: <br />❑ e. loan guarantee <br />❑ f. loan insurance <br />Year Quarter <br />Date of Last Report: <br />4. Name and Address of Reporting Entity. <br />5 If Reporting Entity in No. 4 is Subawardee, Enter Name <br />❑ Prime <br />and Address of Prime: <br />❑ Subawardee Tier (it known) <br />Congressional District if known <br />Congressional District if known <br />6. Federal Depart menl/Agency <br />7. Federal Program Name /Description: <br />CFDA Number (if applicable) <br />8. Federal Action Number (if known) <br />9. Award Amount (if known) : <br />S <br />10. a. Name and Address of Lobbying Registrant <br />b. Individuals Performing Services (including address if <br />(if individual, last name, first name, Nf! : <br />different fmm No. 10a.) (last name, first name, Mt): <br />(attach Continuation Sheet(s) SF- LLL -A, if necessary) <br />(attach Continuation Sheet(s) SF•LLL -A, if necessary) <br />11. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply): <br />$ actual planned <br />❑ a. retainer <br />❑ b. one-time fee <br />❑ c. commission <br />12. Form of Payment (check all that apply): <br />❑ d. contingent fee <br />❑ a. cash <br />❑ e. deferred <br />❑ b. In -kind; specify: Nature <br />❑ 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 Sheet(s) SF- LLL -A, if necessary): <br />15. Continuation Sheel(s) SF -LLL -A attached: ❑ Yes ❑ No <br />16. Information requested through this form is authorized by <br />Signature: <br />title 31 U. S. C. section 1352, This disclosure of lobbying <br />activities is a material representation of fact upon which <br />reliance was placed by the tier above when this transaction <br />Print Name: <br />was made or entered into. This disclosure is required <br />pursuant to 31 U. S. C. 1352. This information will be <br />Title: <br />reported to the Congress semi - annually and will be <br />available for public inspection. Any person who fails to file <br />Telephone No: Date: <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 />[Federal Use Only <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions <br />searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send <br />comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the <br />Office of Management and Budget Paperwork Reduction Project (0348.0046) Washington D. C 20503 <br />