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CITY OF SANTA ANA <br />PROPOSAL <br />PROJECT NO.: 18-2681 <br />CENTENNIAL LAKE CIRCULATION RENOVATION <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />COMPLETE THIS FORM TO DISCLOSE LOBBYING ACTIVITIES PURSUANT TO 31 U.S.C. 1352 <br />1. Type of Federal Action: 2. Status of Federal 3. Report Type: <br />Action: <br />= a. contract a. bid/offer/application a. initial <br />b. grant b. initial award b. material change <br />c. cooperative agreement c. post -award <br />d. loan For Material Change Only: <br />e. loan guarantee year quarter <br />f. loan insurance date of last report <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, <br />Enter Name and Address of Prime: <br />Prime Subawardee <br />Tier , if known <br />Congressional District, if known <br />6. Federal Department/Agency: <br />8. Federal Action Number, if known: <br />10. a. Name and Address of Lobby Entity <br />(If individual, last name, first name, MI) <br />11. <br />12. <br />14. <br />Congressional District, if known <br />7. Federal Program Name/Description: <br />CFDA Number, if applicable <br />9. Award Amount, if known: <br />b. Individuals Performing Services (including <br />address if different from No. I Oa) <br />(last name, first name, MI) <br />(attach Continuation Sheet(s) if necessary) <br />Amount of Payment (check all that apply) 13. Type of Payment (check all that apply) <br />$ actual ❑ planned a. retainer <br />b. one-time fee <br />Form of Payment (check all that apply): c. commission <br />ea. cash d. contingent fee <br />b. in -kind; specify: nature e deferred <br />value f. other, specify <br />Brief Description of Services Performed or to be performed and Date(s) of Service, including <br />officer(s), employee(s), or member(s) contacted, for Payment Indicated in Item 11: <br />(attach Continuation Sheet(s) if necessary) <br />15. Continuation Sheet(s) attached: Yes ❑ No ❑ <br />16. Information requested through this form is authorized by <br />Title 31 U.S.C. Section 1352. This disclosure of lobbying <br />reliance was placed by the tier above when his transaction <br />was made or entered into. This disclosure is required <br />pursuant to 31 U.S.C. 1352. This information will be <br />reported to Congress semiannually and will be available for <br />public inspection. Any person who fails to file the required <br />disclosure shall be subject to a civil penalty of not less than <br />$10,000 and not more than $100,000 for each such failure. <br />Federal Use Only: <br />Signature:_ <br />Print Name: <br />Title: <br />Telephone No.: <br />Date: <br />Authorized for Local Reproduction <br />Standard Form - LLL <br />Add No. One <br />P-24 of P-25 <br />