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Pt. 21, App. B 31 CFR Subtitle A (7-1-06 Edition) <br /> APPENDIX B TO PART 21—DISCLOSURE FORM TO REPORT LOBBYING <br /> DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> 031&W16 <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 <br /> (See reverse for public burden disclosure.) <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> a.contract a. bid/offer/application a. initial filing <br /> b.grant b.initial award b.material change <br /> c.cooperative agreement For Material Change Only: <br /> c. post-award B <br /> d.loan <br /> e.loan guarantee year quarter <br /> f. loan insurance date of last report <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee,Enter Name <br /> 0 Prime ❑ Subawardee and Address of Prime: <br /> Tier ,if known: <br /> Congressional District,if known: Congressional District,if known: <br /> 6. Federal DepartmenVAgency: 7. Federal Program Name/Description: <br /> CFDA Number,if applicable: <br /> B. Federal Action Number,if known: 9. Award Amount,if known: <br /> 10. a. Name and Address of Lobbying Entity b.Individuals Performing Services(including address if <br /> (if individual,last name,first name,MI): different from No.10a) <br /> (last name,first name,Mn: <br /> (attach Continuation Sheet(s)5f-ILL-A,If necessan) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> $ 0 actual 0 planned ❑ a. retainer <br /> 0 b.one-time fee <br /> 12. Form of Payment(check all that apply): 0 c.commission <br /> 0 a. cash 0 d.contingent fee <br /> 0 b.in-kind;specify: nature ❑ e.deferred <br /> P �' ❑ f. other;specify: <br /> P N <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including officerls),employee(s), <br /> or Member(s)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation Sheet(s)SF-[11-A,it necessary) <br /> 15. Continuation Sheel(s)SF•LLL-A attached: 0 Yes 0 No <br /> 16. information requested through this form it authonrnd by title 31 U.s.C. <br /> section :.This disclosure of lobbying gunfire is a material repmsenlo.ae Signature: <br /> ni fact upon rhkA nlirtc.wa p4ced by the tier above.,hen this <br /> ores m,e.,,.retrial into.this dilctawrt h required panuant to Print Name: <br /> t u3.C.1353.This information rill be npon.d to lb.Congress semi. <br /> ann.m.ay and ouch be.,wabee fog pudic inspection am person who fees to Title: <br /> fiw the mitered dmlosure shall be wbject to a tnd penalty d not less than <br /> sto.aoo,nd not more tnan 13m.00s for.ach such Wore. Telephone No.: Date: <br /> i[411ev4t€he Authorized f«local Reproduction <br /> stattdara r«m-w <br /> 262 <br />