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DocuSign Envelope ID: BOFE06B7-70C7-44D2-A46C-D4lE904EED9B <br /> Contract Number 00041659/ Page 21 of 22 <br /> Disclosure Of Lobbying Activities <br /> (Approvad by OMB 0344.0046) <br /> Complete this form to tiisic.lia i3.lobbyirlg a EiVifi s 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, Bid/offer/applicallon a. Initial filing <br /> ❑ b. grant ❑ b. Initial Award H b. material change <br /> ❑ c, cooperative agreement ❑ c, Post-Award <br /> For Materlal Chan a Onl <br /> ❑ d, loan.... 9 y;... ... . <br /> ❑ e. loan guarantee <br /> ❑ f, loan Insurance Year _Quarter <br /> Date Of Las(Report: <br /> 4. Name and Address of Reporting Entity: S. If Reporting Entity In No.4 is Subawardee, Enter Name and <br /> Address of Prime: <br /> ❑ Prime <br /> ❑ Subawardee Tier (if known) <br /> Congressional District(if known) Congressional District(if known) <br /> B. Federal Departmenl./Agency: 7. Federal Program NamelDescriptiow <br /> CFDA Number(if applicable) <br /> p. Federal Action Number(if known) 9. Award Amount(if known)$ <br /> 10. a, Name and Address of Lobbying Entity b, Indlviduals performing Services(including address it different <br /> (If Individual,last name, first name, M0, from No. 10a.) (last name, first name, MO: <br /> (attach continuation Shoat(s)SF-UL A,if nacassaty) (attach Continuation Sheet(s)SF-LU-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(chock all that apply): ❑ c, commission <br /> ❑ d• contingent fee <br /> ❑ a. cash ❑ e. deferred <br /> ❑ b. In-klnd; specify: Nature ❑ f. other;specify: <br /> Vacua <br /> 14. Brief Description of Services Performed or to be Performed and Dates)of Services,Including offlcer(s),employee(s), or Member(s) <br /> contacted,for Payment Indicated in Item 11(altach Continuation Shoel(s)SP-ILL-A,Ifnecossery): <br /> 16. Continuation Sheets)SF-LLL-A attached: ❑ Yes ❑ No <br /> 16, Information requested through(his form is authorized by Signature: <br /> title 31 U. S.C. section 1362, This disclosure of lobbying <br /> acllvl(les Is a material representation of fact upon which Print Name: _ <br /> reliance was placed by the(ter above when this transaction <br /> was made or entered Into. This disclosure Is required Title: <br /> pursuant to 31 U. S.C, 1362. This information will be <br /> reported to the Congress semi-annually and will be Telephone No: Date: <br /> available for publlc Inspection. Any person who falls to ilia <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 /> r , �r _ Authorized for Local Reproduction <br /> �;ad *' ` ,.,_ n Standard Form-•LLL <br /> 12 <br />