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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 aPDr°'ee b°h'e <br /> OSN-noan <br /> Complete this form to disclose lobbying activities pursuant to 11 U.S.C.1357 <br /> (See reverse(Cr public burden disclosure., <br /> I. Type of Federal Action 2. Status of Federal Action: 3. Report Type: <br /> ❑ a. contract ❑ a. bidlofferlapplication O a. initial filing <br /> b.grant b.initial award b.material change <br /> c. cooperative agreement c. post-award For Material Change Only: <br /> e.loan year quarter <br /> e.loan guarantee dale of last report <br /> b loan insurance <br /> 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee.Enter Name <br /> and Address of Prime: <br /> 0 Prime ❑ Subawardee <br /> Tier .(known: <br /> Congressional District.(known: Congressional District.if known: <br /> 6. Federal DepadmenuAgtncy. 1. Federal Program Name:Description: <br /> CFDA Number,if applicable'. <br /> 5. Federal Action Number,rf known: 9. Award Amount,d known: <br /> 10. a.Name and Address of Lobbying Entity b.lndividuah Performing Services(Including address if <br /> of individual,last name,first name,Mb: different from No t0a7 <br /> but name,first name,Mll: <br /> intact,Coniinuanen sheer{h)Sf.LL1-A of necessam <br /> II. Amount of Payment(check all that apply): 13. Type of Payment[check all that apply?: <br /> f 0 actual ❑planned 0 a.retainer <br /> 0 b.one-time fee <br /> 12 Form of Payment(check all that apply?: 0 c-commission <br /> ❑ a.cash 0 d.contingent fee <br /> 1 nature 0 e.deferred <br /> ❑ b.in-kind;specify: ❑ I. other:specify: <br /> value <br /> 14. Brief Description of Services Performed or to be Performed and Dales)of Service,including officerlsf.employeets), <br /> or Memberts)contacted,tor Payment Indicated in Item II: <br /> ?attach Connn.alren Sheerb}SFall-A A nauwswr) <br /> 15, Continuation Sitwell')SF-I.LL-A attached: Cl Yes ❑No <br /> It, uNmoan fscryw .d e•e4.awn Nen a anhoroed S ,n"Si u.SL.... �,,.. <br /> .tISt nor.bwfoa w.4 t.lgv4 sow a ,.M ian...slsens+r o Sfgrrature- <br /> .a fur lion.ncn wa »...N..d to rMo...br..:Pon,v.. PriM Name, <br /> ,.ede..wore n..en,~awe ...pond gun"... <br /> 3,i tt c.rasa Thu h+e...a.w...a nre..d in Os Coro..... idle: <br /> .....,and.r a...a,al. rr.,e <br /> rr n"�°xrie+ice.n.x 1.1 m.`M°�'�at <br /> wa 4r Telephone No: Date: <br /> Imam.nd roe ire..Nan{1m.dm b e.rh...h r.ree. <br /> ���a . ..►►... .. . Rebate+(la Kcal aep,adxenon <br /> T .araa`eT - Sunda(tem-LLL <br /> 262 <br />