Form 4040-0013 SF-LLL Disclosure of Lobbying Activities (SF-LLL)

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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Z,p

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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
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer