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r <br /> v <br /> Federal Register Vol.54.No.243/Wednesday,December 20,1989/Notices 52323 <br /> DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB <br /> Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 <br /> (See reverse for public burden disclosure.) <br /> 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: <br /> a. contract a. bid/offer/application a. initial filing <br /> b. grant b. initial award b. material change <br /> c. cooperative c. post award <br /> agreement For Material Change Only: <br /> d. loan year quarter <br /> e. loan guarantee <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 <br /> Prime Subawardeq—i Name and Address of Prime: <br /> Tiei I , if known: <br /> Congressional District, if known: 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 /> 10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address <br /> (if individual, last name, first name, MI): if different from No. 10a) <br /> (last name, first name, MI): <br /> (attach Continuation Sheet(s) SF-LLL-A, if necessary) <br /> 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): <br /> $ p actual pljled p a. retainer <br /> b. one-time fee <br /> c. commission <br /> 12.1i5orm of Payment(check all that apply): d. contingent fee <br /> a. Cash e. deferred <br /> b. In-kind; specify: nature: f. other; specify: <br /> value: <br /> 14. Brief Description of Services Performed or to be Performed and Date(s) of Service,including officer(s), <br /> employee(s), or member(s) contacted,for payment indicated in item 11: <br /> (attach Continuation Sheet(s)SF-LLL-A if necessary) <br /> 15. Continuation Sheet(s) SF-LLL-A attached: YeC No <br /> 16. Information requested through this form is authorized by title 31 0 <br /> U.S.C.section 1352. This disclosure of lobbying activities is a Signature: <br /> material representation of fact upon which reliance was placed by <br /> the tier above when the transaction was made or entered into. This Print Name: <br /> disclosure is required pursuant to 31 U.S.C. 1352. This information <br /> will be reported to the Congress semi-annually and will be available <br /> for public inspection. Any person who fails to file the required Title: <br /> disclosure shall be subject to a civil penalty of not less than <br /> $10,000 and not more than$100,000 for each such failure. Telephone No.: Date: <br /> Federal Use Only: Authorized for Local production <br /> Standard Form-LLL <br /> 6 <br /> H - 2 <br />