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21 <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 /> 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 <br /> Quarter <br /> Date Of Last <br /> Report: <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee,Enter <br /> Name and Address of Prime: <br /> ❑ Prime <br /> ❑ SubawardeeTier (if known) <br /> Congressional District(if known) <br /> 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 <br /> (if individual, last name,first name,MI): address if different from No. IOa.) (last name, <br /> first name, MI): <br /> (attach Continuation Sheet(s)SF-LLL-A, if necessary) <br /> 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 /> $ ❑ actual ❑ a. retainer <br /> ❑ planned ❑ b. one-time fee <br /> ❑ c. commission <br /> 12. Form of Payment(check all that apply): ❑ d. contingent fee <br /> ❑ e. deferred <br /> ❑ a. cash ❑ f. other; specify: <br /> ❑ b. In-kind; specify: Nature <br /> Value <br /> 14. Brief Description of Services Performed or to be Performed and Date(s) of Services,including officer(s), <br /> employee(s),or Member(s)contacted, for Payment Indicated in Item I I(attach Continuation Sheet(s) SF-LLL-A, if <br /> necessary): <br />