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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 /> 03464016 <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 /> Oa.contract ❑ a. bid/offer/application f-1 a. initial filing <br /> b.grant b.initial award f I b.material change <br /> c.cooperative agreement c. post-award For Material Change Only: <br /> .loanyear quarter <br /> e.loan guarantee <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 /> ❑ Prime 0 Subawardee and Address of Prime: <br /> Tier ,it known: <br /> Congressional District,if known: Congressional District,if known: <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 /> 10. a. Name and Address of Lobbying Entity b.Individuals Performing Services(including address if <br /> (if individual,last name,first name,Mil: different from No.10a) <br /> (last name,first name,MI): <br /> (attach Continuation Sheens+SFLLL-A r/necessa+yl <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> 5 ❑actual ❑planned ❑ a. retainer <br /> ❑ b.one-time fee <br /> 12. Form of Payment(check all that apply): 0 c. commission <br /> El a.cash ❑ d.contingent fee <br /> ❑ b.in-kind;specify: nature ❑ e.deferred <br /> P �' ❑ f. other;specify;p fy: <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Dates)of Service,including officerlsl,employees!, <br /> or Member(s)contacted,for Payment Indicated in Item 11: <br /> ianach Continuation 5heetul SF11.1.-A if necessaM <br /> 15. Continuation Sheet(s)SF.LLL.A attached: ❑Yes ❑No <br /> 1C Mannation r.ps,.wd tAmuah Ni.torn,n aurhodod br tip sr LISC. <br /> section MS.mn disclosure ti lobbying activities Is a material rae..nut on Signature: <br /> d tact upo.Which.a.u.s.a placed by Ilw tier abo...Mn this <br /> t.a.s.c.wn.a made re entered into.mis ditbmhe is round post/ant to Print Name. <br /> 11 U.S.C.last.ma i/on.arion.al be reported to the Conan.rani <br /> annually end will b...wile to,public impaction.My person who team to Title. <br /> N.the rewired disclosure dull be subject m a ciao penalty 01 not lest than <br /> tto.000 and not more then sun.om Iow wads sod.Loon. Telephone No.: Date: <br /> reiOfalthe Omit: btntwrised rt r Local Reproduction <br /> Standard Four-to <br /> 262 <br />