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<br /> 10 <br />Disclosure Of Lobbying Activities <br />(Approved by OMB 0344-0046) <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br /> <br />1. Type of Federal Action: <br /> <br /> a. contract <br /> b. grant <br /> c. cooperative agreement <br /> d. loan <br /> e. loan guarantee <br /> f. loan insurance <br /> <br />2. Status of Federal Action: <br /> <br /> a. Bid/offer/application <br /> b. Initial Award <br /> c. Post-Award <br />3. Report Type: <br /> <br /> a. initial filing <br /> b. material change <br /> <br />For Material Change Only: <br /> <br />Year___________ Quarter____________ <br />Date Of Last Report:_________________ <br /> <br />4. Name and Address of Reporting Entity: <br /> <br /> Prime <br /> Subawardee Tier (if known) ________________________ <br /> <br />Congressional District (if known) _________________________ <br /> <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />Address of Prime: <br /> <br /> <br /> <br />Congressional District (if known) ________________________ <br />6. Federal Department/Agency: <br /> <br />7. Federal Program Name/Description: <br /> <br /> CFDA Number (if applicable) ________________________ <br /> <br />8. Federal Action Number (if known) <br /> <br />9. Award Amount (if known) $ <br /> <br />10. a. Name and Address of Lobbying Entity <br /> (if individual, last name, first name, MI): <br /> <br /> <br /> <br />(attach Continuation Sheet(s) SF-LLL-A, if necessary) <br /> b. Individuals Performing Services (including address if different <br />from No. 10a.) (last name, first name, MI): <br /> <br /> <br /> <br />(attach Continuation Sheet(s) SF-LLL-A, if necessary) <br />11. Amount of Payment (check all that apply): <br /> <br /> $ € actual € planned <br /> <br />13. Type of Payment (check all that apply): <br /> <br /> a. retainer <br /> b. one-time fee <br /> c. commission <br /> d. contingent fee <br /> e. deferred <br /> f. other; specify: _____________________________ <br /> <br />12. Form of Payment (check all that apply): <br /> <br /> a. cash <br /> b. In-kind; specify: Nature <br /> Value <br /> <br />14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s) <br />contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary): <br /> <br /> <br />15. Continuation Sheet(s) SF-LLL-A attached: Yes No <br /> <br />16. Information requested through this form is authorized by <br />title 31 U. S. C. section 1352. This disclos ure of lobbying <br />activities is a material representation of fact upon which <br />reliance was placed by the tier above when this transaction <br />was made or entered into. This disclosure is required <br />pursuant to 31 U. S. C. 1352. This information will be <br />reported to the Congress semi-annually and will be <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 /> <br />Signature: <br /> <br />Print Name: <br /> <br />Title: ______________________________________________ <br /> <br />Telephone No: Date: <br />Federal Use Only Authorized for Local Reproduction <br />Standard Form - LLL <br /> <br />DocuSign Envelope ID: A80A68F0-12D3-42DA-80C7-45C66A2BB398