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DISCLOSURE OF LOBBYING ACTIVITIES
Approved by OMB

Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352

0348-0046

Review Public Burden Disclosure Statement

1. * Type of Federal Action:

2. * Status of Federal Action:

3. * Report Type:

a. contract

a. bid/offer/application

a. initial filing

b. grant

b. initial award

b. material change

c. cooperative agreement

c. post-award

d. loan
e. loan guarantee
f. loan insurance

4. Name and Address of Reporting Entity:
Prime

SubAwardee

5. If Reporting Entity in No.4 is Subawardee, Enter
Name and Address of Prime:

* Name

Street 2

* Street 1

* City

State

Zip

Congressional District, if known:

7. * Federal Program Name/Description:

6. * Federal Department/Agency:

CFDA Number, if applicable:

8. Federal Action Number, if known:

9. Award Amount, if known:
$

10. a. Name and Address of Lobbying Registrant:

b. Individual Performing Services (including address if
different from No. 10a)

Prefix

* First Name

Middle Name

* Last Name

* Street 1

* City

Prefix

Suffix

Street 2

Middle Name

* First Name

* Last Name

Suffix

Street 2

* Street 1

State

Zip

11.
Information requested through this form is authorized by title 31 U.S.C. section
1352. This disclosure of lobbying activities is a material representation of fact
upon which reliance was placed by the tier above when the transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be reported to the Congress semi-annually and will be available for
public inspection. Any person who fails to file the required disclosure shall be
subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.

State

* City

* Signature:

Zip

Completed on submission to Grants.gov

*Name: Prefix

* First Name

Middle Name

Suffix

* Last Name

Title:
Telephone No.:
Date:

Federal Use Only:

Completed on submission to Grants.gov
Authorized for Local Reproduction
Standard Form - LLL (Rev. 7-97)