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• CITY OF SANTA ANA • ~1 I ~ "- N Ul'U, <br />PROJECT NO. 08-5018: TRAFFIC SIGNAL INSTALLATION ON HAZARD AVE & ROSITA ST <br />PROJECT N0.08-5019: TRAFFIC SIGNAL INSTALLATION ON HAZARD AVE E/O GATES ST <br />. PROJECT NO. 08-5020: TRAFFICSIGNAL MODIFICATION ON MCFADDEN AV & NEWHOPE AV <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Co lete this form to disclose lobb ~n activities ursuant to 31 U.S.C. 1352 <br /> <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 b. 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 Inswance date of last 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 known <br />Con essional District, tfknown Con essional District, ifknown <br />6. Federal Department/Agency: 7. Federal Program Name/Description <br /> CFDA Number, If 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 (mrluclarg aclc~ ifchffar~atfiamNo. <br />c~illa~rnrt~~M~ 1~) <br />(~.~ ~ <br />(attach Continuation Sheet(s) if neces ) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply) <br />$ ^ Actual ^ Plarnred ^ 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, <br />14. Brief Description of Services Perfom~ed or to be performed and Date(s) of Service, including officer{s), employee(s), or rr~mber(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.Irregtr~edthrotrglrthis fonnis autltc~dbyTide 31 USC Section <br />1352. Thisdiscloaueoflobbyi<rgaclivifgsisamalaialreatirnoffactupm Signature <br />whidrreliatrevv~plaoedbythetiaabovewhenthehvuumadeora~aed <br />' Erno President <br />~ <br />it~ho. <br />Ilnsdiscbs~ueisregtmadptasiatrtto3lU.S.C.1352. This~w~lbe Print Name <br />. <br />repa~dtotheCa~ssseiiri-a<aa~allyaudw~beava>lablef~p~licn f/ <br />Arrypasaiwhofar7slofiletheragtmeddisclosueshallbeUoacivrlpa~akyof Title <br /> <br />notlessttr~ut$IO,OOOatrlmtmgethan$100,000foreaclrsu~lrfa>~e. ~ ~y, /~ <br />Tel hone No. -~(/U~`1~~~ Date `!~ ~ ~~ <br />Feda-alUse ~ Authorized for Local Rc~roduction <br /> Standard Form-LLL <br />r] <br />L <br />TO BE INCLUDED IN BID PACKAGE <br />BP 26 of 32 <br />