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4. Name and Address of Reporting Entity 

• Enter the name of the business or organization. 
• Enter the address of the business or organization, including city, state, and zip code. 
• Enter the Congressional District of the business or organization.  

5.  Name and address of Prime 

• This field is only applicable if the information included in No. 4 pertains to a subawardee. 
• If subawardee information entered in No. 4, enter the name and address of the Prime in the space provided at No. 5. 

6. Federal Department/Agency 

Enter the name of the Federal Department or Agency making the award. 

7. Federal Program Name/Description 

• Enter the Name of the Federal Program, i.e., SBIR or STTR. 
• Enter the CFDA number. 

8. Federal Action Number 

Enter the FOA number. 

9. Award Amount 

Enter the award amount. 

10.a.  Name and Address of Lobbying Registrant 

• Enter the first and last name of the lobbying registrant. 
• Enter the address of the lobbying registrant, including street, city, state, and zip code. 

10.b. Individual Performing Services 

• Enter the first and last name of the individual performing services. 
• Enter the address of the individual performing services, including street, city, state, and zip code. 

11.  Signature 

• Provide a signature at the signature line. 
• Enter the first and last name of the authorized representative signing the document. 
• Indicate the title of the authorized representative. 
• Enter the date signed.