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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 /> 03a&Wa6 <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 /> El a.contract 11 a. bid/offer/application nia.initial filing <br /> b.grant b.initial award b.material change <br /> c.cooperative agreement For Material Change Only: <br /> d.loan c. post-award B <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 DeparlmenVAgency: 7. Federal Program Name/Description: <br /> CFDA Number,if applicable: _ <br /> 8. Federal Action Number,if known: 9. Award Amount,if known: <br /> $ <br /> 10. a. Name and Address of Lobbying Entity b.Individuals Performing Services(including address if <br /> (if individual,last name,first name,Mt): different from No.10a) <br /> (last name,first name,MI): <br /> (attach Con nn nation Sheet(s)SF-tN-A if necessary) <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): ❑ c.commission <br /> ❑ a.cash 0 d.contingent fee <br /> nature ❑ e.deferred <br /> ❑ b.in-kind;specify: <br /> ❑ f. other;specify: <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s), <br /> or Member(s)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation 5heet(r)SF-ILL-,is if necessary) <br /> 15, Continuation Sheet(s)SF-LLL-A attached: 0 Yes 0 No <br /> 16. Information requested through this form h authorized by title 31 U.S.C. <br /> ion n5r.This d'ncbrm d ebbyina actmtles it a matmJ npmsentation Signature: <br /> d fact upon whicA Mwc.wa pI .d by the tier above when Chit <br /> wx mad.«.nt.,.d into.this dacbwrt h required punu»t to Print Name: <br /> 31 U.S.C.1351.BM information.tin be,.ported to the Congress semi- <br /> annually and tin be&volable for public inynction Any p.mn who tact to Title: <br /> file the meowed d6closu,e shall he subject to a civil penalty of not less than <br /> 11a.000.nd mon man itm.00a r«uch wch mlun. Telephone No.: Date: <br /> F Authorized for tonal Meprodlaction <br /> Slaldud form-Ill <br /> 262 <br />