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CITY OF SANTA ANA <br />PROJECT NO. 11 -6733: LYON STREET REHABILITATION FROM EDINGER TO CHESTNUT <br />0 FEDERAL PROJECT NO. ESPL 5063(138) <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities numinnt tn I t t i c C i zs') <br />1. Type Federal Action <br />2. Status of Federal Action <br />3. Report Type: <br />❑ a. Contract <br />❑ a. Bid/offer /application <br />❑ a. initial <br />b. t <br />b. initial award <br />b. material change <br />C. Co rate Agreement <br />c, post -award <br />d. Ban <br />For Material Change only: <br />e. Loan G tee <br />Year quarter <br />f. Loan Irtstuan <br />date of last report <br />4. Name and Address of R rting Entity <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />Address of Prime: <br />❑ Prime ❑ Subwarde <br />Tier If known <br />Congressional District, f known <br />Congres sional District, f known <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description <br />CFDA Number, If applicable <br />8. Federal Action Number, if known <br />9. Award Amount, if known <br />$ <br />. Name and Address of Lobbying Entity <br />b. Individual Performing Services (inchdmg ad-,hw ffd0e wfiomNo. <br />rka�lcatn�n� fo tLl� <br />10a) <br />(last nwwfhY AV <br />(attach Continuation <br />Sh t(s) if necessary) <br />11. Amount of Payment (check all that apply): <br />13. of Payment (check all that apply) <br />$ ❑ Actual ❑ Planned <br />a. retainer <br />b. one -time fee <br />❑ C. sion <br />12. Form of Payment (check all that apply): <br />❑ a. cash <br />❑ d co ent fee <br />❑ b. in -kind; specify: nature <br />❑ e. deferr <br />value <br />❑ f. other, sm <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s , loyee(s), or member(s) contacted, for <br />Payment indicated in item 11: <br />(attach Continuation Sheet (s) f necessa ) <br />15. Continuation Sheets) attached: ❑ Yes ❑ No <br />Ot 09 <br />16Iotommbm equcstcditmghthisfmnisatdhormedbyTid e31USCSection <br />1352. Tlisdkbsnofi&bymgac&kiesisanmtaWrqxesmtafimoffidupm Signature <br />which reliance was placed by the tier above when the hawctlm was nude cr armed <br />mb. ThisdiscbsueisWwedptmW1b31U .S.C1352. Thisinftarmtionwlllbe Print Name ���y} j� I <br />mportedtothe Cor>gtess sera- ar�andwtbeavatlableforpubiic i Wecfi <br />Arrypeasonwhofaalstofilethere4meddi9closneshaIlbetoacivrlp=ltyof Title �(l PrPSi <br />rtot less than $10,000 a nd rut more than $100,000 fix each sttch &lee. <br />Telephone No. — Date Gf a61 <br />Use Only. Authorized for Local Reprod on <br />Standard Form —LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 23 of 29 <br />