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Pt.21, App, B 31 CFR Subtitle A(7-1-06 Edition) <br /> APPENDIX B TO P AT&T 21—DISCLOSURE FORM To REPORT L01113 VING <br /> DISCLOSURE OF LOBBYING ACTIVITIES ANAAA1 by OMB <br /> C134.44/45 <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 <br /> (See reverse far public burden disclosure) <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3, Report Type: <br /> ri co.trao Ei a. bidrofferrapplication a.initial filing <br /> b.grant b.initial award b mate.material change <br /> c.cooperative agreement Pm Material Change Only: <br /> d.loan postravvard <br /> e.loan guarantee year quarter <br /> 1 loan insurance date of last report <br /> 4, Name and Address of Reporting Entity: F. If Reporting Entity in No.4 is Subawarder.Enter Manor <br /> and Address of Prime: <br /> 0 Prime 0 Subawardee <br /> Tier ,if knows: <br /> Congressional District,lf known, Congressional District,,f known: <br /> 5. Federal Department/Agency: 7, Federal Program NamerDescription: <br /> (FDA Nforber, 1 applicable: <br /> 5. Federal Action Number tf known: 5. Award Amount,II known; <br /> 10. a.Name and Address of Lobbying Entity b.lath's,'Rituals Performing Services hrtchrdshe address it <br /> el+,ndneicival,last nanne,Isrst name,Mt:: different Iron,No.Mas <br /> (last name,first name.With <br /> 'mare ceheeeatem SheNe(s)SYULA Fr nrcesSaryt <br /> 11 Amount of Payment(cheek all that apply,: 13. Type of Payment(check a/l that apply?; <br /> $ 0 actual 0 planned CI a. retainer <br /> 0 b one-time fee <br /> 12. Form of Payment(check all that applya: 0 L.co.,,missicm <br /> LI a.casts CI d.contingent tee <br /> 0 e.0 b.in-kind;specify: nature deterrevalue <br /> 0 f. other;specify: <br /> 14. brief Description of Services Performed or to be Performed and Dagels}of Service,including officerfst employeeist <br /> or Memberist contacted,for Payment Indicated in Item Ili <br /> brook CoolAtortrori StAc1(3)5F-UIA art cessseti <br /> 1$ Continuation Sheens/SF4.11,4 attached 0 Yes 0 No <br /> If. Inlymettso Apented thoto#:tdo holt o AA:AAA in OA St SF SC. <br /> AAA 1352 rhii dratiaa.at iobbrog actontes.or nutonel esptenotyton Sig"4"."' <br /> ot AY 3..Idol tyltroce Oat itined by Ar tter*boys art../INd <br /> ototoroto on fordo.sotend Ytto mu.44Anonk sword port'.,: Print Name: <br /> Sr 443 C.I,.rott YoknortA:.05 to Ay*ty 50.Go:AAA tottry <br /> an.aa.y art,walSo avadtabia in prbite At:AAA Yety Anon othr Nett to 1144' <br /> ter yr.,oqom dinfootto AA too.04.0 ursaMork A oot.444 dun <br /> SAADO Ad no nor*An IMLAY to, set Telephone No.: Date: <br /> 262 <br />