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Page 17 of 53 <br />FORM 4.06 DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <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: 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 <br /> (if individual, last name, first name, MI): <br />b. Individuals Performing Services <br />(including address if different from No. 10A) <br />(last name, first name, MI): <br />Information requested through this form is authorized by title 31 U.S.C. <br />section 1352. This disclosure of lobbying activities is a material <br />representation of fact upon which reliance was placed by the tier above <br />when this transaction was made or entered into. This disclosure is <br />required pursuant to 31 U.S.C. 1352. This information will be available for <br />public inspection. Any person who fails to file the required disclosure <br />must be subject to a civil penalty of not less than $10,000 and not more <br />than $100,000 for each such failure. <br />Signature: <br />Print Name: <br /> Title: <br />Telephone No.: Date: <br />Federal Use Only:AuthorizedforLocal <br />Reproduction <br />StandardFormLLL(Rev.7-97) <br />(See next page for instructions.)