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AUTHENTICATED <br /> 11S_G OVERNMENT <br /> INFORMATION <br /> GPO <br /> Pt. 21,App.B 31 CFR Subtitle A(7-1-06 Edition) <br /> APPENDIX$TO PART 21—DISCLOSURE FORM TO REPORT LOBBYING <br /> DISCLOSURE OF LOBBYING ACTIVITIES Appmned byOMR <br /> ali{0016 <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C.13S2 <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 King <br /> b.grant b.initial award b.material change <br /> c.cooperative agreement <br /> d.loan c.post-award For Material Change Only. <br /> e.loan guarantee year quarter <br /> I. loan insurance date of last report <br /> 4. Name and Address of Reporting Entity: 9. If Reporting Entity In No.4 is Subawardee,Enter Name <br /> CIPdme CI Subawardee <br /> and Address of Prime: <br /> Tier ,if known: <br /> Congressional District,it known: Congressional District if known: I; <br /> 6. Federal Department/Agency: 7. Federal Program Name/Description: <br /> CFDA Number,if applicable: <br /> 8. Federal Action Number,if known: 9. Award Amount,if known: <br /> S � <br /> to. a.Name and Address of lobbying Entity b.Individuals Performing Services(including address if <br /> (if individual,last name,first name,M11: 'different from No.10a) <br /> (last name,first name,MI): <br /> (mach Cenr,nvation ShelV/O SA/U-4 If nannwa n) <br /> 11.Amount of Payment(check all that apply): 13.Type of Payment(check all that apply): <br /> $ 0 actual ❑planned ❑ a.retainer <br /> ❑ b.one-time fee <br /> 12. Form of Payment(check all that apply): 0 c.commission <br /> ❑ a.cash ❑ d.contingent fee <br /> ❑ b.In-land;specify: nature ❑ e.deferred <br /> ❑ f. other;specify: <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,tnciuding of(icer(s),employeefs), <br /> or Member(s)contacted for Payment Indicated In Item 11: <br /> (mach Continuation Jh!!r(t)5F4.14A if aeeerta,e) <br /> 15. Continuation Sheets)SF.LU..A attached: 0 Yes ❑No <br /> 16. s kernel n,requend rr.waS d.h Ione It enlwr<N 6r nA al 115G <br /> .nti>,nsa.DN.Sdeo,.d bbblltea.ee,(Ihe A...until rep.nnurbn Signature: <br /> d tot open uheh reliance ern p4aed b/the On above erh,n lhi. <br /> Innoabn.....do eaDred 6n>nu,aide....h,.gored per.,.nl to Print Name: <br /> It USG rest.ih:.Lavnnsibn a be,.pvtd to do Come..tneh <br /> a,vele and war be legatee roe poE+e/nap.eua.ens pollen who td.to Thle: <br /> 6h the tege6ed dhde.w Jul b.,ubf.ct lea old pmary d,.sr ins than <br /> Max and mu men shmj MOM Bedh loch hawl. Telephone No.: Date: <br /> '£4g 92^f{�sit limit - r <br /> �� A s 1 3� 1 1 t(�t> L71c, R t slapted a dorm w a P°dulnon <br /> 262 <br />