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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 OMa <br /> O3.6-0046 <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 in a. bichofferlapplication a. 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 y: <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 DeparimenVAgency: 7. Federal Program Name/Description: <br /> CFDA Number,of applicable: <br /> 8. Federal Action Number,if known: 9. Award Amount,of known: <br /> 10. a.Name and Address of Lobbying Entity b.Individuals Performing Services(including address if <br /> Of individual,last name.first name,b10: different from No.that <br /> (last name,fast name,KW; <br /> (attach Contnuation Sheeibl 5F.ttt.A,f never sar) <br /> tt. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> S 0 actual 0 planned 0 a.retainer <br /> ❑ b.one-time fee <br /> 12. Form of Payment(check all that apply): 0 c.commission <br /> ❑ a. cash 0 d.contingent fee <br /> 0 b.in-kind;specify: nature ❑ e.deferred <br /> p N' ❑ 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 Members)contacted,for Payment Indicated in Item 11: <br /> (attach Continuation Sheet(s)SF-ttd'A if necessary) <br /> 15. Continuation Sheets)SF.LL1.4 attached: 0 Yes 0 No <br /> 16. Wooauon,.Quested thoush M,1 tom n.nro,ued by toile 1t usc. <br /> ten1111rn).disele ee laa„narngo.,;,,n.a.«wwiwomnatwn Signature: <br /> of tact upon.loch,.lunc.We peed by the on, un.e when Oho <br /> toneecOon.as made ea mowed,no n.n&Jeiom.n,egwrw run..,'to Print Name: <br /> to u s c 1152 Pew YM.manon.i be epod.a to d..Conpee sera:. <br /> smokily and.a be«a ieb a to,poe,he mooch...Mr pence who I.J.,o <br /> met the roomed diedosun.lull be tubiect a a arvd penJry d not Wes.ban <br /> sxi.mo end not um.Own slumold owl,loch Lulu. Telephone No.: Date: <br /> Fed. Vile Y sra Audsrel a to wd Rapod�.ton ndud rwrit-w. <br /> 262 <br />