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DocuSign Envelope ID:B749018F-351A-4D6F-9FC5-C2EB21856524 <br /> Consolidated Agreement FY22 Page 26 of 27 <br /> Disclosure of Lobbying Activities <br /> (Approved by OMB 0348-0046) <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> ❑ a. contract ❑ a. Bid/offer/application ❑ 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 /> ❑ Prime and Address of Prime: <br /> ❑ Subawardee Tier (if known) <br /> Congressional District if 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 Registrant b. Individuals Performing Services (including address if <br /> (if individual, last name, first name, Ml): different from No. 10a.)(last name, first name, Ml): <br /> attach Continuation Sheets SF-LLL-A, if necessary) attach Continuation Sheets SF-LLL-A, if necessary) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> $ u actual a 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 Sheet(s) 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 <br /> title 31 U. S. C. section 1352.This disclosure of lobbying Signature: <br /> activities is a material representation of fact upon which <br /> reliance was placed by the tier above when this transaction Print Name: <br /> was made or entered into. This disclosure is required <br /> pursuant to 31 U. S. C. 1352.This information will be Title: <br /> reported to the Congress semi-annually and will be <br /> available for public inspection.Any person who fails to file 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 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,searching existing <br /> data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.Send comments regarding the burden estimate <br /> or any other aspect of this collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction <br /> Project 0348-0046,Washington,D.C.20503 <br />