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Docusign Envelope ID: 50585F21 -A738-4303-BD3F-60841076ED5E <br /> Disclosure Of Lobbying Activities Contract Number 00048145 / Page 29 of 30 <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): Elc. commission <br /> ❑ do 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. Room <br /> f tlelrel LJse:On%11 %,y Authorized for Local Reproduction <br /> Standard Form - LLL <br />