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________ <br /> <br />________ <br /> _____________ <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES (FTA) <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br />(See next page for instructions.) <br />1.Type of Federal Action: <br />a. contract <br />b. grant <br />c. cooperative agreement <br />d. loan <br />e. loan guarantee <br />f.loan insurance <br />2.Status of Federal Action: <br />a. bid/offer/application <br />b.initial award <br />c.post-award <br />3.Report Type: <br />a.initial filing <br />b.material change <br />For Material Change Only: <br />year quarter <br />date of last report <br />4.Name and Address of Reporting Entity: <br />Prime Subawardee <br />Tier , if known : <br />Congressional District , if known : 4c <br />5.If Reporting Entity in No. 4 is a Subawardee, Enter Name <br />and Address of Prime: <br />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 />$ <br />10.a. Name and Address of Lobbying Registrant b.Individuals Performing Services (including address if <br />( if individual, last name, first name, MI ): different from No. 10a ) <br />(last name, first name, MI ): <br />11.Information requested through this form is authorized by title 31 U.S.C. section <br />1352. This disclosure of lobbying activities is a material representation of fact <br />upon which reliance was placed by the tier above when this transaction was made <br />or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This <br />information will be available for public inspection. Any person who fails to file the <br />required disclosure shall be subject to a civil penalty of not less than $10,000 and <br />not more than $100,000 for each such failure. <br />Signature: <br />Print Name: <br />Title: <br />Telephone No.: Date: <br />Federal Use Only: Authorized for Local Reproduction <br />Standard Form LLL (Rev. 7-97)