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<br />• <br />.] <br />CITY OF SANTA ANA <br />PROJECT NO. 08-5017: TRAFFIC SIGNAL INSTALLATION ON WILLITS ST & SULLIVAN ST <br />PROJECT NO. 08-5021: TRAFFIC SIGNAL INSTALLATION ON RAITT ST & GLENWOOD AVE <br />PROJECT NO. 08-5022: TRAFFIC SIGNAL INSTALLATION ON HARBOR BLVD & KENT AVE <br />PROJECT NO. 08-5023: TRAFFIC SIGNAL MODIFICATION ON SANTA ANA BL & FLOWER ST <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose IobbyinQ activities pursuant to 31 U.S.C. 1352 <br />NINE. <br />1. Type of Federal Action 2. Status of Federal Action 3. Report Type: <br />^ a. Contract ^ a. Bid/offer/application ^ a. initial <br />b. Grant b. initial award h. material change <br />c. Corporate Agreement c, post-award <br />d. Ban For Material Change only: <br />e. Loan Guarantee Year quarter <br />f. Loan Insurance date of last re rt _ <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br /> Address of Prime: <br />^ Prime ^ Subwardee <br />Tier , If krwwn <br />Con essional District, if known Con essional District, i known <br />6. Federal Department/Agency: 7. Federal Program Name/Description <br /> CFDA Number, If a licable <br />8. Federal Action Number, if known 9. Award Amount, if known <br /> <br />10. a. Name and Address of Lobbying Entity b. Individual Performing Services (including crldress~d~fer~tifrorrcNo. <br />(.:frelit~a~ ~StrrAr~ f~M/) ICIZ) <br />(lastncm~ firstrunn~ MI) <br />(attach Continuation Sheet(s) if necess ) <br />11. 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 />12. Form of Payment (check all that apply): ^ c. commission <br />^ a. cash ^ d. contingent fee <br />^ b. in-kind; specify: nature ^ e. deferred <br />value ^ f. other, s i <br />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 <br />Payment indicated in item 11: <br />(attach. Continuation Sheet(s) i necessary) <br />15. Continuation Sheet(s) attached: ^ Yes ^ No <br />16. Irilixrr>allon n~quesled duough this form is atlrttoti~d by Title 31 USC Section <br />1352.'~hisdisclostneoflobbyingactivitiesisamaterialrelxesartaaonoffactupon Signature <br />which reliance vtas plaoad hythe tier-above when die harisaclion was made orc~ttered <br />into. 'I}usdisclostQeist~urtudputsuarttto3l U.S.C.1352. 'll»sinfonnationwtll be Pr-nt Name <br />reponad to the Congress semi-annuaIly and will be available forpublic inslxcfioa <br />Any person who fails rv file the tequued disclosure shall be subject to ac7vil penalty of Title <br />rtot less than $10,000 and rrctt mere than $100,000 foreach such failure. <br /> Tele hone No. Date <br />Federal Use Only: Authorized for Local Reproduction <br /> Standa~ Form - LLL <br />BP 28 of 34 <br />TO BE INCLUDED IN BID PACKAGE <br />