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DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB
0348-0046

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

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

For Material Change Only:
Quarter:

Date of last report:
5. If Reporting Entity in No. 4 is Sub-awardee, Enter Name and
Address of Prime:

Sub-Awardee
Tier

a. initial filing
b. material changes

Year:

4. Name and Address of Reporting Entity:
Prime

3. Report Type:

, if known

Congressional District, if known

Congressional District, if known

6. Federal Department/Agency:

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 Entity
(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 than $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)
Electronic Form Version Designed in Adobe 7.1 Version

INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether sub-awardee or prime Federal recipient, at the invitation 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 Conger, an officer or employee of Congress, or an employee of a Member of Congress
in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is
inadequate. 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 is a follow-up report cause 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 sub-awardee recipient. Identify
the tier of the the sub-awardee, e.g., the first sub-awardee of the prime is the 1st tier. Sub-awards include but are not limited to
subcontracts, sub-grants and contract awards under grants.
5. If the organization filing the report in item 4 check "sub-awardee", 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 entity 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. Enter the amount of compensation paid or reasonably expected to be aide by the reporting entity (item 4) to the lobbying entity
(item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all Boxes that apply. If this is
a material change report, enter the cumulative amount of payment made or planned to be made.

According to the Paperwork Reduction Act of 1995, 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 0348-0046. The time required to complete this information is
estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection.

DISCLOSURE OF LOBBYING ACTIVITIES
CONTINUATION SHEET

Reporting Entity:

Approved by OMB
0348-0046

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Authorized for Local Reproduction
Standard Form - LLL-A (Rev. 7/97)