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C'I'~i' t3~ SANTA AIWA <br /> <br /> • PR03ECT NO.OS-3195 <br /> PROPOSAL AND CONTP`ACT AGREEMENT <br /> BISCI~~S~[JR~ L®B~'II~G ACT~TIES <br /> NOiVE <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. curial <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 Insurance date of last report <br /> 4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Nanie and <br /> Address of Prime: <br /> ? Prime ? Subwardee <br /> ` Tier ,Ifk~iorana <br /> CongressionalDishict, iflt~aortna CongressionalDishict, ifknoit~a <br /> 6. Federal Department/Agency: 7. Federal Program Nanle/Description <br /> CFDA Number, If applicable <br /> 8. Federal Action Number, if Inaortna 9. A«'ard Amount, i. <br /> f k~aov~a <br /> $ <br /> 10. a. Name and Address of Lobbying Entity b. Individual Performir-ig Services (mdud~ag aclrhr?sr ifrliffea~aatfinmNo. <br /> t ~ ~ uif r~ Ic~iun7~ fns Nd IOa) <br /> I (lnstrarnare, <br /> fnstiarn~a~ ll~ <br /> ` (attach Continuation Sheet(s) if necessary) <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. Foml of Payment (check all that apply): ? c. conariission . <br /> ? a. cash ? d. contingent fee <br /> ? b. in-kind; specify: nature _ ? e. deferred <br /> value ? f. other, specify <br /> 14. Brief Description of Sen~ices Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, <br /> l for Payment indicated in item 11: <br /> i (attach Continuation Sheet(s) ifaaecessmy) <br /> 15. Contuiuation Sheet(s) attached: ? Yes No <br /> 16.Infom~lioma-~>es~citln-ou~rthisfomris autl~rizedbyTide31USCSection <br /> 1352. Tl>isdiscloslueoflobbyingactivitiesisarrrnterialr~rltatianoffactupon Signatlrre <br /> . ~~rrichreliar~m~vaspLacedbythetierabove~vl~nthetr-~Lactionuasn,adeorerrter~d <br /> izrto. Thisdiscl~ueisregrm~ed~>3r~tto31U.S.C.1352. ThisinfomRlion~~llbe Print Name ZIEBARTH <br /> reprnted to flr°, Cong ess sen~arnb~y ar~i wry l~ a~arlable for public ir~~ec:tion . <br /> Arryp_=r~onv,~o fails b file fly, req<mzd cbsclosrue sl>aIllx subjectto a civrl p~iahy of Title PRESIDIIVT <br /> rrotless than$10,000 aradnotrr~t2 tlnrr $100,000 for eachsuchia~.ue. <br /> Telephone No. 714 992-5151 Date 04 22 10 <br /> Fed°ralUse Otlly Authorized for Local Reproduction <br /> Standard Form - LLL <br /> TO BE USED FOR FEDERALLI' FUNDED PR03ECTS OiL'LY <br /> TO BE INCLUDED IN BID PACKAGE <br /> BP2o~fZ~, <br /> <br />