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CITY OF SANTA ANA <br />• PROPOSAL NO. 10-7504 <br />PROPOSAL AND CONTRACT AGREEMENT <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 Action 3. Report Type: <br />^ a. Contract ^ a. Bid/offer/application ^ a. initial <br />b. Grant h. 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 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 known <br />Con essional District, i 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, f known 9. Award Amount, if known <br /> <br />. a. Name and Address of Lobbying Entity h. Individual Performing Services (including aklressifdi~ererrtfromNo. <br />(~nrdit~adre~ kutr~nG fug Ml) I ~i) <br />(kcstncm~e,. firstnan~ M/) <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), employees}, or member(s) contacted, for <br />Payment indicated in item 11: ~~ ~ ~~~ ~~ ~ /~ <br />- <br />~" <br />(attach Continuation Sheets <br />) i <br />necessa ) <br />I5. Continuation Sheet(s) attached: ^ Yes ^ No ,~~'" <br />16. Infom~anon requested through this form is au~tarized by Title 3l USC Se~ion _~ <br />_~=~j <br />~~ <br /> <br />1352. This discbsure oflobbying activities is a material repn~entation of fact upon W <br />~ <br />T~y <br />Signature ~ :~-~ <br />which reliance was placed by the tier above when the t-arisaction was made or entered ~~~' ~ G~ ~ ~~~ `~~ <br />into. This disck~ is required pursuant to 31 U.S.C.1352. This infomration will be Print Name <br />reported totheCongresssemi-annually and will be available forpublic inspection. '.,--~,.-,, t-~-- <br />1~ I ~- <br />Ti <br />l <br />Any person who fails to file the required disckrsure shall be subject to acivil penalty of t <br />e <br />not less than $]0>000 and not more than $]00,000foreachcuch failure. 1' <br />Tele hone No.1 ~~.rJSI.P. ~~-~~`i' Date ~4.2(~ • ~ ~ <br />Use Only: Authorized for Local Reproduction <br /> Standa~z3 Fom~ - LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 25 of 31 <br />