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Approved by OMB <br />0348-0046 <br />Disclosure of Lobbying Activities <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />(See reverse for public burden disclosure) <br /> <br />1. Type of Federal Action: <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 /> a. bid/offer/application <br /> _____ b. initial award <br /> c. post-award <br /> <br />3. Report Type: <br /> a. initial filing <br /> _____ b. material change <br /> <br />For material change only: <br />Year _______ quarter _______ <br />Date of last report___________ <br /> <br />4. Name and Address of Reporting Entity: <br /> ____ Prime _____ Subawardee <br /> Tier______, if Known: <br /> <br /> <br /> <br /> <br /> <br /> Congressional District, if known: <br />5. If Reporting Entity in No. 4 is Subawardee, Enter <br />Name and Address of Prime: <br /> <br /> <br /> <br /> <br /> <br /> <br /> Congressional District, if known: <br />6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> <br /> <br /> <br />CFDA Number, if applicable: __________________ <br /> <br />8. Federal Action Number, if known: 9. Award Amount, if known: <br /> <br />$ <br />10. a. Name and Address of Lobbying Registrant <br /> (if individual, last name, first name, MI): <br /> <br /> <br /> <br /> <br />b. Individuals Performing Services (including address if <br />different from No. 10a) <br /> (last name, first name, MI): <br />11. Information requested through this form is <br />authorized by title 31 U.S.C. section 1352. This <br />disclosure of lobbying activities is a material <br />representation of fact upon which reliance was placed <br />by the tier above when this transaction was made or <br />entered into. This disclosure is required pursuant to 31 <br />U.S.C. 1352. This information will be reported to the <br />Congress semi-annually and will be available for public <br />inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less <br />than $10,000 and not more than $100,000 for each such <br />failure. <br /> <br />Signature: __________________________________ <br /> <br />Print Name:_________________________________ <br /> <br />Title:______________________________________ <br /> <br />Telephone No.: ________________ Date: _______ <br /> <br />Federal Use Only <br /> <br />Authorized for Local Reproduction <br />Standard Form - LLL (Rev. 7-97) <br /> <br />Docusign Envelope ID: CF064D56-F89A-8651-8229-D168AFF8B909