Sf Lll

DISCLOSURE OF LOBBYING ACTIVITIES
Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352

1. * Type of Federal Action:

2. * Status of Federal Action:

4040-0013

3. * Report Type:

a. contract

a. bid/offer/application

b. grant

b. initial award

b. material change

c. cooperative agreement

c. post-award

For Material Change Only:

a. initial filing

d. loan

quarter

year

e. loan guarantee
date of last report

f. loan insurance

4. Name and Address of Reporting Entity:
Prime

SubAwardee

Tier if known:

* Name
* Street 1

Street 2

* City

State

Zip

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 Registrant:
Prefix

Middle Name

* First Name

* Last Name

Suffix

* Street 1

Street 2
State

* City

Zip

b. Individual Performing Services (including address if different from No. 10a)
Prefix

Middle Name

* First Name

* Last Name

Suffix

* Street 1

Street 2

* City

11.

State

Zip

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 the 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.

* Signature:
*Name:

Prefix

* First Name

Middle Name

* Last Name

Title:

Federal Use Only:

Suffix

Telephone No.:

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