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CITY OF SANTA ANA <br />PROJECT NO. 12 -7532: PLAZA SANTA ANA <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSL7RE OF LOBBYING ACTIVITIES <br />Complete [his form [o disclose lobbvine activ irics pursuant fn '� 1 1 I C C 1452 <br />1. Type of Federal Ac -lion <br />2. Status of Federal Ac-[ion <br />3. Report Type: <br />Q a. Contract <br />Q a. Bid/otier/ lication <br />app <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 />Por Material Change only - <br />e. Loan Guarantee <br />Year quarter <br />f. Loan Insurance <br />date of last re rt <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 Q Subwardee <br />Tier , ljknown <br />Con ssional District, i known <br />Con essional District, r lozown <br />6. Federal DepartrnendAgency: <br />7. Federal Program Name/Description <br />CFDA Number, If• livable <br />S. Federal Action Number, fknown <br />9. Award Amount, if/orown <br />O. a. Name and Address of Lobbying Entity b. Individual Performing Services (arlrrfag acfias�a6,�rv�tfrp�nNo. <br />(rfrrfttir�{lz�rrm :fvs; Mj 1(kz) <br />(/e�ramr�.�"5t tzmten �i <br />(attac;h Continuation Shoet(s) ifnece� ) <br />1 l . Amount of Paymen[ (check all that apply): <br />13. 'type of Payment (check all that apply) <br />$ � Actual � Planned <br />� a. retainer <br />b. one -time fee <br />� c. commission <br />12. Forth of Payment (check all that apply): <br />Q a. cash <br />� d. contingent tee <br />Q b. in -kind; specify: nature <br />� e. deferred <br />value <br />� t: other, s i ' <br />14. Brief Description of Services Performed or to be performed and Dates) oi'Service, including oiiicer(s), employee(s), or members) contacted, for <br />Payment indicated in item 1 1 : <br />(attach Continuation Sheets) i necessa <br />15. Continuation Sheets) attached: Yes � No <br />16. Infcxrrramorl tegr�ed through this tixm is ar8l�i�t by TNe 31 USC SeL�DII <br />- <br />1352. " Ihisd�9el osraeof' lobbyingactivitiesisarrr�aialtepcscxnationofiactupon <br />Signature. <br />wliidi reliarrcewas placed by the tiaabove wtrar tl-letr-arsaction was rrrade or aNaod <br />vVO. Thisdiscbs<aeis regtritad��r -r!�t to31 U.S.C.1352. 'ibis infianialion will be <br />Print Name . , <br />report+ adtatheCongrc�sani�rnuallyanciwillbeavailabletorpublicirtgraction. <br />� � f7 / � <br />Anypc�sa�whofailsroSleUieralrmeddiscl m- taeshallbesubjecttoacivilparaltyof' <br />Title Iw7a1�IHyT /t ✓G�-d <br />r-� <br />rot less than $10,000 and rotnlore than $100,(X701ar®d� such tallrue <br />Dy /l7•%L <br />Tele honeNo.lr / Date <br />TO BE INCLUDED IN BID PACKAGE <br />BP 24 of 30 <br />