Attachment 1 SF-LLL.doc

RFP-10-0004

DISCLOSURE OF LOBBYING ACTIVITIES

Approved by OMB Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 (See reverse for public burden disclosure.)

1. Type of Federal Action:

FORMCHECKBOX

a. CONTRACT

b. GRANT

c. COOPERATIVE AGREEMENT

d. LOAN

e. LOAN GUARANTEE

f. LOAN INSURANCE

2. Status of Federal Action:

FORMCHECKBOX

a. BID/OFFER/APPLICATION

b. INITIAL AWARD

c. POST-AWARD

3. Report Type

FORMCHECKBOX

a. INITIAL FILING

b. MATERIAL CHANGE

FOR MATERIAL CHANGE ONLY:

YEAR QUARTER

DATE OF LAST REPORT

4. Name and Address of Reporting Entity

FORMCHECKBOX

PRIME FORMCHECKBOX

SUBAWARDEE

TIER , IF KNOWN:

Congressional District, if known:

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

Congressional District, if known:

CFDA Number, if applicable:

10a. Name and address of Lobbying Entity

Attach Continuation sheet(s)

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

10A) (last name, first name, MI)

SF LLL-A, if necessary

11. Amount of Payment (check all that apply):

$ FORMCHECKBOX

actual FORMCHECKBOX planned

13. Type of Payment (check all that apply):

FORMCHECKBOX

a. RETAINER

FORMCHECKBOX

b. ONE-TIME FEE

FORMCHECKBOX

c. COMMISSION

FORMCHECKBOX

d. CONTINGENT FEE

FORMCHECKBOX

e. DEFERRED

FORMCHECKBOX

f. OTHER; SPECIFY:

12. Form of Payment (check all that apply):

FORMCHECKBOX

a. cash

FORMCHECKBOX

b. in-kind; specify: nature value

14. Brief Description of Services performed or to be Performed and Date(s) of Service, including offer(s), employees(s), Member(s) contacted, for Payment indicated in item 11:

(attached Continuation sheets(s) SF-LLL-A, IF NECESSARY)

15. Continuation Sheet(s) SF-LLL-A attached: FORMCHECKBOX Yes FORMCHECKBOX No

11. Information requested through this form is authorized by title 31 U.S.C.

section 1352. This disclosure of lobbying activities is a material repre-sentation of fact upon which reliance was placed by the tier above when this transaction was made or entered into. this information 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:

Printed Name:

Title:

Telephone No.: Date:

Federal Use Only:

AUTHORIZED FOR LOCAL REPRODUCTION

Standard Form - LLL

ATTACHMENT 1