Sf Lll

Approved by OMB No. 0348-0046

DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
(See Reverse for public burden disclosure.)
1. Type of Federal Action:

2. Status of Federal Action:

a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance

a. initial filing
b. material change
For Material Change Only:

a. bid/offer/application
b. initial award
c. post-award

year
quarter
date of last report

4. Name and Address of Reporting Entity:

5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:

Subawardee

Prime

3. Report Type:

Tier

, if known:

Congressional District, If known:
6. Federal Department/Agency:

Congressional District, If known:
7. Federal Program Name/Description:

CFDA Number, if applicable:
8. Federal Action Number, If known:

9. Award Amount, If known:
$

10. a. Name and Address of Lobbying Registrant
(If individual, last name, first name, MI):

b. Individuals Performing Services (Including address if
different from No. 10a)
(last name, first name, MI):

11. Information requested through this form is authorized by title 31 U.S.C.
section 1352. This disclosure of lobbying activities is a material
representation of fact upon which reliance was placed by the tier above
when this transaction was made or entered into. This disclosure is
required pursuant to 31 U.S.C. 1352. This information will be reported to
the Congress semi-annually and will be available for public inspection.
Any person who fails to file the required disclosure shall be subject to a
civil penalty of not less that $10,000 and not more than $100,000 for
each such failure.

Federal Use Only:

Signature:
Print Name:
Title:
Telephone No.:

Date:
Authorized for Local Reproduction
Standard Form LLL (Rev. 7-97)

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of
a covered Federal action, or a material change to a previous filing pursuant to title 31 U.S.C. section 1352. The filing of a form is required
for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a
covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing
guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered
Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this a followup report caused by a material change to the information previously
reported, enter the year and quarter in which the change occurred, Enter the date of the last previously submitted report by this
reporting entity for this covered Federal action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the
appropriate classification of the reporting entity that designates if it is, or expects to be a prime or subaward receipt. Identify the tier
of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts,
subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks :Subawardee," then enter the full name, address, city, State and zip code of the
prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency
name, if known. For example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog of Federal
Domestic Assistance (CFDA) number for grants, cooperative agreements, loans and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in Item 1 (e.g., Request for Proposal
(RFP) number; Invitation for bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the
application/proposal control number assigned by the Federal agency). Include prefixes, e.g. "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of
the award/loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged
by the reporting entity identified in Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First
Name and Middle Initial (MI).
11. Certifying official shall sign and date the form, print his/her name, title and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB
Control Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of
information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction
Project (0348-0046), Washington, DC 20503.