Standart Form Lll - Disclosure Of Lobbying Activities - U.s. Equal Employment Opportunity Commission

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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

4040-0013

1. * Type of Federal Action:

2. * Status of Federal Action:

3. * Report Type:

a. bid/offer/application

a. contract

a. initial filing

b. grant

b. initial award

b. material change

c. cooperative agreement

For Material Change Only:

c. post-award

d. loan

year

quarter

e. loan guarantee

date of last report

f. loan insurance

4. Name and Address of Reporting Entity:

Prime

SubAwardee

Tier if known:

* Name

* Street 1

Street 2

* City

State

Zip

Congressional District, if known:

6. * Federal Department/Agency:

7. * Federal Program Name/Description:

CFDA Number, if applicable:

8. Federal Action Number, if known:

9. Award Amount, if known:

10. a. Name and Address of Lobbying Registrant:

Middle Name

Prefix

* First Name

* Last Name

Suffix

* Street 1

Street 2

* City

State

Zip

b. Individual Performing Services

(including address if different from No. 10a)

Middle Name

Prefix

* First Name

* Last Name

Suffix

* Street 1

Street 2

* City

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.

* Signature:

*Name:

Prefix

* First Name

Middle Name

* Last Name

Suffix

Title:

Telephone No.:

Date:

Authorized for Local Reproduction