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DocuSign Envelope ID:A6134E61D-095E-4A51-9823-BOEE0861F374 <br /> onttr ct,.Nu ber QQ041435, Amendment Number 4/ Page 19 of 20 <br /> Disclosure O Lob�ying ctivltles <br /> (Approved by OMB 0344-0046) <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 /> and Address of Prime: <br /> ❑ 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 Entity 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 Sheet(s)SF-LLL-A, if necessary) (attach Continuation Sheet(s)SF-LLL-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 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 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 /> Federal Use Only Authorized for Local Reproduction <br /> Standard Form - LLL <br />