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CITY OF SANTA ANA <br />PROJECT NOS. 12 -6753, 12 -7531, & 11 -2618 <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Cmm�lete chic f o r m to licnlner Inht 6 rt o, «;.A *; T f e r ­1 <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 />❑ 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 quarter <br />f. Loan Insurance <br />date of W ort <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 />❑ Prime ❑ Subwardee <br />Tier If known <br />Congressional District, i known <br />Congressional DL*ict, i known <br />6. Federal Department/Agency: <br />7. Federal Prograrn,,Mme/Description <br />CFDA Number, If applicable <br />8. Federal Action Number, fknown <br />9. Award'Amount, ifknown <br />-'s <br />10. a. Name and Address of Lobbying Entity <br />b. Individual Performing Services (erg aaEtr~csifdrf/ardfrornNo. <br />(�frrh lWn7nq,fislAlp ' <br />Ilkr) <br />(kd namftgnww M9 <br />attar Continuation <br />Shee 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. 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, specify <br />14. Brief Description of Services PWrmed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, for <br />Payment indicated in item 11: <br />attach Continuation Sheets i necess <br />15. Continuation Sh attached: Yes Ll No <br />16. Infonw6on reque�l�nough this form is a>Ihoria d by Tide 31 USC Secpon <br />1352. This disclosuar,6fobbyingactivitiesisamabia lrgx onoffactupon <br />Signature X - <br />which reliance plaoad by thetierabove when thetransaction was madeorentem 1 <br />into. This ' istequiredpursuantto31 U.S.C. 1352 This infom26onwiilbe <br />Print Name ICHAEL J. CARVER <br />repottedtb Congressserniannually and will be available forpublic ¢specbm <br />Any whofasbfilethe► equireddiscloaueshallbesubjecttoaavilpamllyof <br />Title PRESIDENT <br />not than $10,000and not more than$100,000foreachsuchfa ue. <br />Tele hone No. 714) 637 -1550 Date FEBRUARY 8, 2012 <br />Federal Use Only: <br />Authorized for Local Reproduction <br />Standard Form — LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 25 of 31 <br />