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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 El a. bid/otter/application a.initial filing <br /> b.grant b.initial award b.material change <br /> c, cooperative agreement For Material Chan a Only: <br /> d.loan c. post-award H <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 /> S. Federal DeparlmentAgency: 7. Federal Program Name/Description: <br /> CFDA Number,if applicable: <br /> & Federal Action Number,if known: 9. Award Amount,1f known: <br /> S <br /> 10. a. Name and Address of Lobbying Entity b.Individuals Performing Services tincluding address if <br /> lit indwrdtal,last name,lest name,MI): drit'erent hom No.10a) <br /> (last name•first name,M0: <br /> latmch Conimtunan Blu-ytt SFtti,S.d netesvay) suss suss <br /> 11. Amount of Payment(check all that apply): 13_ Type of Payment(check all that apply): <br /> E ❑actual ❑planned 0 a retainer <br /> ❑ b.one-time fee <br /> 12- Form of Payment(check all that apply): ❑ c. commission <br /> 0 a.cash ❑ d contingent fee <br /> ❑ b.in•kind;specify: nature ❑ e.deferredp ry' ❑ f. other:specify: <br /> p h- <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including olficer(s),employeets), <br /> or Memberls)contacted for Payment Indicated in Item 11: <br /> tan,ch tgntmoa sun rMnrtu%1,11.1.4 to neceumy) <br /> 15. Continuation Sheens)SF•LLL•A attached: 0 Yes ❑No <br /> 1& It. bun request.]doo.eh dole form n suborned by bile 31 u s c <br /> mama nsa it..anions.of lobbyna chutes w a reu.w/ng.nnWban Signature <br /> d fat upon which r.fience fray placed by lM tier above when lha <br /> trensmoon .,mude or entered Ina n.0 ns.w...n resumed penmen n Print Name: <br /> t u s C nsa nm inknnm.real be..posed to e..Cure.....- <br /> .nmsdly end Mil ha.oaele for public*spar Lien Any poor,.5n full a Title: <br /> h1e the remand dlnhwre dud be s bf.c.to a awl penahy d not taus than <br /> Mow....us nnw.hn 1100000 kr we,such haluo Telephone No.: Dale: <br /> 1,4*td the Oar a.o wiad toe areal Reproduction <br /> Stand]]rum-to <br /> 262 <br />