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CITY OF SANTA ANA <br />PROJECT NO. 10-6704: TRAFFIC SIGNAL INSTALLATION ON CIVIC CENTER DR 8c PACIFIC ST <br />PROJECT NO. 10-6705: TRAFFIC SIGNAL INSTALLATION ON 17Tt' ST 8c KING ST <br />PROJECT NO. 12-6763: BRISTOL ST BIKE LANE EXTENSION FROM EDINGER AV TO MCFADDEN AV <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form [o disclose lobbvine activities pursuant to 3l U.S.C. 1352 <br />1. Type of Federal Action <br />a <br />Contr <br />t 2. Status of Federal Action ?) <br />Q <br />Bid/ <br />tF <br />/ <br />li <br />i <br />n ? 3. Report Type: / <br />? <br />i <br />i <br />i <br />l ` _ <br />. <br />? /? <br />ac <br />/ <br />?? er <br />a. <br />o <br />app <br />cat <br />o a. <br />n <br />t <br />a <br />b. Grant <br />/ b. initial award b. material change <br />a 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 re ort <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br /> <br />Q Prime ? Subwardee ? /? Address of Prime: <br />'?} /? <br />Tier lfknowr <br />Con essional District, i known Con ssional District, i known <br />6. Federal Departrnent/Agency: 7. Federal Program Name/Description N <br />/ <br /> CFDA Number, If a livable <br />8. Federal Action Number, fFoxowr ? 9. Award Amount,tfknowr <br />? T \ <br /> $ <br />10. a. Name and Address of Lobbying Entity (rrcLr.¢Gng nrfbncc rfcd?SrrBjrnrrr No. <br />b. Individual Performing Servic <br />e <br />s <br />(?izfviir>{kRrrrrgrv?N? ? /? <br />// f <br />? <br />? <br />' (lcaTr?reefostn.?re, Mn ] \' l /? <br />/ r \ <br />` <br />attach Continuation Sh s if recess ` <br />11. Amount of Payment (check all that apply): / <br />$ ? Ach?al ? Planned ? <br />/ /1. 13. Type of Payment (check all that apply) <br />0 a. retainer <br />/ <br />7?? 0 b. one-time fee <br />12. Form of Payment (check all that apply): Q c. commission <br />a. cash Q d. contingent fee <br />b. in-kind; specify: nature ? e. deferred <br />value ? f. other, s ci <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or memb r(s) contacted, for <br />Payment indicated in item 11: <br />? <br />` <br />attaci: Continuation Sheets 'recess <br />15. Continuation Shee s attached: Yes No -? <br />16. Ittfcarrt?on tegt?d ilncx>gltthis farm is ?rtlwri?d by Title 31 USC Section <br />1352.'IltisdisclosiaeofloblryQ?gxtivitiesisamate?ialrepesa?atiortoffactupon Signature <br />which reli?re was placed by the tia above when thehaisacdut was made a erred <br />'vVO.7lvsdisclosuleistegtmedputsuarrtto3lUS.C.1352."Ihisinforrrr?mwillbe Print Name VQ <br />\ <br /> <br />teQntadht the Congers sari-?nelly ?dwill be avaik?ble fiapublic it?xctiai 1? <br />?'C e S ? ? e 1?-\ <br />i <br />l <br />Arrypasonwhof?lsh?filetheregtmeddiscJostaeshallbesulJjecxtoacivlpataltyof T <br />t <br />e <br />rot less drat $10,000 and trkmote than $100,000 for each such faltae. <br />Tele honeN -p2lo - Date S 23 (2 <br />Feda-al Use Only: Authorized for Local Rep uction <br /> Standard Forrn - LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 26 of 32