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CITY OF SANTA ANA <br />PROJECT NO. 10 -7558 CENTENNIAL PARK RESTROOM ROOF REPLACEMENT <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIYITIE.S <br />Complete thin fnrm in rtiaclnae lnhhvino aMiviNec .� r.r rr• Z t i T C !` l'i CO <br />1. Type of Federal Action <br />2. Status of Federal Action <br />3. Report Type: <br />� a_ Contract <br />� a. Bid/offer /application <br />0 a. initial <br />b. Grant <br />b. initial award <br />b. material change <br />c. Corporate Agreement <br />c, post -award <br />d. Ban <br />For Material Change only: <br />e. Loan Guarantee <br />Year y„�rt,� <br />f. Loan Insurance <br />date of last re _ <br />4. Name and Address of Reporting Entity <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />Address of Prime: <br />Q Prime � Subwardce <br />Tier , Iflalown <br />Con Tonal District, i /otolvrl <br />Con 'opal District, i lotown <br />6. Federal Department/Agency: <br />7. Federal Program Name /Description <br />CFDA Number, If livable <br />8. Federal Action Number, 1f'IOlOTNIt <br />9. Award Amount, if/ozown <br />a. Name and Address of Lobbying Entity b. Individual Performing Services (uicbtding addr+"cr�differaufiarnNo. <br />T�rd�.d'� �TYrlC7t�,J69,MI) IQa) <br />(1a�+i�. fvszr�ti� 11�1I) <br />attach Continuation Sheets) if neces ) <br />11. Amount of Payment (check all that apply): <br />l 3. Type of Payment (check all that apply) <br />$ Q Actual � Planned <br />� a. retainer <br />� b. one -time fee <br />� c. commission <br />12. Form of Payment (check all that apply): <br />a- cash <br />Q d. contingent fee <br />b. in -kind; specify: nattse <br />Q e. deferred <br />value <br />Q f. other, <br />14. Brief Description of Services Performed or to be performed and Dates) of Service, including officer(s), employee(s), or members) contacted, for <br />Payment indicated in item 1 L• <br />(attach Continuation Shee s) i cessa ) <br />15. Continuation Shee s attached: Yes No <br />16. Lduniationnad thiougli this foan is aalio<iadbylitie 31 USC Section <br />1352 Tlrisdivclau= eoflobbymga�vitiesisarr�lione £factupon <br />Signature <br />whichreliarlce was placedby the Zia above whal the he�aaroit was madeorer�ied <br />into. Thisdisclos:eistecgmedr.��*m31 U.S.C.1352 Thsiirtoarradonwlllbe <br />Print Name <br />n;xitdd to the Congas sar>ia�xraIly atld wl-Il be available forpublic u>Spection. <br />Anypasonwilofalsk�flethexeqt maddisclnA: eshaIIbesti�jacxtioacavilpataltye�f' <br />Title <br />not less than $IQOOOard rtotmore Iliarl $100;000 fiaeac}i S»Ch falli:e. <br />Tel hone No. Date <br />Feda'al Use �Y• <br />AutlTOiiaed fa Local Reptoducuon <br />Standeid Foiin —I1d. <br />TO BE INCLUDED IN BID PACKAGE <br />BP 23 of 29 <br />