Disclosure of Lobbying Activities

DISCLOSURE OF LOBBYING ACTIVITIES

OMB Number: 4040-0013
Expiration Date: mm/dd/yyyy

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

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[8]
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a. contract

[8J b. grant

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3. • Report Type:

2. • Status of Federal Action:

1. • Type of Federal Action:

c. coopera,we agreement

d. loan

[8J a. m1llal fi1ing

a. bic1/offor/applicaooo

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b. initial award
c. po s 14award

b. matenal Change

o. loan guarontee
f_ loan Insurance

4. Name and Address of Reporting Entity:
OsubAwardee

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•Namo
• succt 1
•c;ry

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Congressional Districl. 1f known:

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Srare

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Stroot 2

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5 1f Reporting Entity in No.4 is Sub;nvardee, Enter Name and Address of Prime:

6. • Federal DepartmenUAgency:

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8. Federal Action Number, if knuwn:

10. a. Name and Address of Lobbying Registrant:
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• Last Name

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• Firsl Namo

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Stare

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• LastNamo
• Strccl 1
• CJly

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· First Name

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Stare

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Suffix

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1oaI

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Middle Name

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Street '2

Suffix

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Zip

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Z1i>

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Information requested through this lorm 1s authonzod by tiitc 31 U.S.C. scctl()n 1352. Ttns dis-Closure of lobbying act1v11tcs is a matenal reprcscolation of fact upon which
reliance was placed by U1e tier i°lt)Ovc when ttie trans'4ction was made or enicred into. This disclosurn is requited pursuan110 31 U.S,C. 1352. 1h15 mformaoon will be rc.-por1ed to
lhc Congress scm.-annually and will oo avall.ablo rcr public 1ospee11on Any person wno fails to file the required disclosure shall De subject to a CMI penally of not loss than
S10,000 and not more than Sl00,000 for each such failure.

• Signature:
•Name:

Title:

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Middle N�me

Street 2

b. Individual Performing Services (.nclvd,ng acoress ,t Mferent from No.
Pro!iK

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CFDA Numbor, ,f appllcablo:

9. Award Amount, if known:

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P,o/Jx.

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7. • Federal Program Name/Description:

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Prefix.

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•t,,as1 Name

Federal Us .& Only:

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• Firsr Name

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Middle Namo

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Telephone No.:

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-·

Suffix

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!Date:

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A.uthorize-d for l�al Reproduction
Standard Form. lll (Rev. 1�1)

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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 4040-0013
The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
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