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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 APPrneed by OMB <br /> 034&W46 <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 /> ni a.contract El a. bid/offer/application a.initial filing <br /> b.grant S.initial award S.material change <br /> c. cooperative agreement <br /> d.loan c. post-award For Material Change Only: <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 /> CI ❑ Subawardee and Address of Prime: <br /> Tier ,if known: <br /> Congressional District,if known: Congressional District,if known: <br /> 6. Federal Department/Agency: 7. Federal Program NameDescription: <br /> CFDA Number,if applicable: <br /> 8. 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 /> Of individual,last name,first name,MII: different from No.10al <br /> (last name,first name,MI): <br /> (attach Cw::nuaion Sheet(,)SF-LILA it necessary) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> S ❑actual 0 planned 0 a. retainer <br /> 0 b.one-time fee <br /> 12. Form of Payment(check all that apply): ❑ c.commission <br /> ❑ a.cash 0 d.contingent fee <br /> ❑ b.in-kind;s eci nature ❑ e.deferred <br /> P ❑ f. other;specify: <br /> value <br /> P <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s), <br /> or Members)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation Sheets)SF-ILL-A,A necessary) <br /> 15. Continuation Sheets)SF-LLL.A attached: 0 Yes 0 No <br /> 16. Woman.,,.qu.oed though does Mn,,ataluexed by tole 31 U.S.C. <br /> sechcc 1352.mn dosclusu.of Jobbr,r1 actmn.s i.,m,terul repre.entanon Signature: <br /> a(rl upon whin iof,,,,.was placed by one ter.bare when this <br /> wa,m.ae ar.nu,ed no.lnt d�uw,,.2 h nganee pwwant m Print Name•. <br /> Os 13 SC 1163.Thu intonation tilt be reported to the congress seem <br /> annually end will be mradae*b pubito insperr goy person who at to Title: <br /> Me the nguir.d dlub„e sna l be,eject to a,s,I penalty of not leas than <br /> f'POW and not mo,e than slgo.loo for each such fads. Telephone No.: Date: <br /> • giNlef11f-Usg Authorised for local Reproduction <br /> Standard Form-art <br /> 262 <br />