ATTACHMENT J.1.02.pdf

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0348-0046 DISCLOSURE OF LOBBYING ACTIVITIES

Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse for public burden disclosure.)

14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment indicated in Item 11.:

2. Status of Federal Action

a. bid/offer/application

b. initial award

c. post-award

3. Report Type:

a. initial filing

b. material change

For Material Change Only:

Year Quarter date of last report

1. Type of Federal Action:

a. contract

b. grant

c. cooperative agreement

d. loan

e. loan guarantee

f. loan insurance

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

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

Congressional District, if known:

4. Name and Address of Reporting Entity:

Prime Subawardee

Tier , if known:

Congressional District , if known:

7. Federal Program Name/Description:

CFDA Number , if applicable:

6. Federal Department/Agency:

Authorized for Local Reproduction Standard Form - LLLFederal Use Only:

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

a. retainer

b. one-time fee

c. commission

d. contingent fee

e. deferred

f. other; specify:

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

a. cash

b. in-kind; specify: nature value

Signature:

Print Name:

Title:

Telephone No.: Date:

16. 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 this 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.

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

$ actual planned

9. Award Amount, if known:

8. Federal Action Number, if known:

b. Individuals Performing Services (including address of different from No. 10a.)

(last name, first name, MI):

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

10. a. Name and Address of Lobbying Entity (if individual, last name, first name, MI):

(attach Continuation Sheet(s) SF-LLL-A, if necessary)

EF