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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 /> 034a-0046 <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 /> ❑ a.contract ❑ ❑a. bid/offer/application a. initial filing <br /> b.grant b.initial award b.material change <br /> c.cooperative agreement 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 /> 0 Prime 0 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 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,MD: -different from No.10a) <br /> (last name,first name,MI): <br /> (attach Continuation Sheet(s)SF-tu.ti,f neCassa,y) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> 0 actual ❑planned 0 a. retainer <br /> ❑ 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;specify: nature 0 e.deferred <br /> P �' ❑ f. other;specify: <br /> P fY <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Dates)of Service,including officer(s),employee(s), <br /> or Member(s)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation Sheets)SF-ILL-A,if necessaM <br /> 15. Continuation Sheet(s)SF•LLL-A attached: 0 Yes 0 No <br /> 16. einmation requened through the form is authorized by title 11 U.S.C. <br /> sthfhth sita.Inth di.cie.ure of lobbying activities is a material representation Signature: <br /> of Net upon which reliance was placed by the tier above when thi. <br /> innwcrgn wa mad.««.t«.d into rd,enclosure is required pursuant to Print Name: <br /> it u.s.C.Iota.Thu information will be reported to the Congress some <br /> annually.rid oat be enthde for pudic in.ection.Any penan who hits to Title: <br /> file the required disclosure,hap be subject to a chit penalty of not less than <br /> 110.e00 and not more than$100.000 for each such torture. Telephone No.: Date: <br /> s 3 t ? Authorised for Local Reproduction <br /> + $tardard Fwm-Ill <br /> 262 <br />