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CITY OF SANTA ANA <br />PROJECT NO. 1 1 -6736 8z l 1 -6746 <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Com lete this form to disclose lobb in activities ursuant to 31 U.S.C. 1352 <br />1 . Type of Federal Action <br />2. Status of Federal Action <br />3. Report Type: <br />Q a. Contract <br />Q a. Bid/ot%r /application <br />0 a. ini <br />b. Grant <br />b. initia] award <br />b. terial change <br />c. Corporate Agreement <br />c, post -award <br />d. Ban <br />For Mate al Change only: <br />e. Loan Guarantee <br />Year quarter <br />f. Loan Insurance <br />da of last re ort <br />4. Name and Address of Reporting Entity <br />5. If Reporting Entity in No. 4 is ubawardee, Enter Name and <br />Address of Prime: <br />Q Prime Q Subwardcc <br />Tier , ]fknown <br />Con ssional District, i '/mown <br />Con ssiona] D' trict, i Imown <br />6. Federal DepartmenUAgency: <br />7. Federal Prow ame/Description <br />FDA Number, If a licable <br />S. Federal Action Number, if/mown <br />9. Award ount, ifkrrown <br />1 O. a. Name and Address of Lobbying Entity ndividual Per-foaning Services (nxlzecCaxg c��essrjc:�fer�errtfit�»vNo. <br />Cjrr�xaEn,' kffirrsn�. fO� M% (knri <br />attach Contin tion Shee s if necess <br />1 1. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply) <br />$ Q Actual Q Planned <br />� a. retainer <br />b. one -time fee <br />� c. commission <br />12. Form of Payment (check al] that apply): <br />a. cash <br />� d. contingent fee <br />b. in -kind; specify: nature <br />� e. deferred <br />value <br />� f. other, s eci <br />14. Brief Description of Services Performed or to rformed and Dates) of Service, including officer(s), employee(s), or members) contacted, for <br />Payment indicated in item ] 1 <br />attach Contimration Sheets i necessa <br />15. Continuation Sheets atfached: Q Yes Q No <br />16. Infrxn�atia t regiresmd throtr�i this f t is by Title 31 USC Sectiort <br />1352. 71�isdisclosiucoflobbyingactivi [iesis n��ialrelxv�balicxtoffactupon <br />Signature ' <br />whichrelia troewasplaoedbytheti�abo ihch�LSactionwasn�adeorarte<ed <br />o '? <br />irrho. Thisdisclostueisregt�adpurc r>;,r,* 31 U.S.C.1352. Thismfon-r�or-rwillbe <br />G� <br />Print Name 'VY 1 <br />rt�tx3d to the Congress will beavailable forpublicinspection <br />-- rr ,^, <br />Any person who fails to file the disclosr ue shall be subjectto a civil pa�alty of <br />Title � C,Q, !t�i� -S 1 C�J�{�, <br />less than $1 0,000 and not than $100,000 fixeach such faihne. <br />_ <br />Tele hone No. %NISI X315 (ACA Date �P I S l �- <br />Fodaal Use Only: <br />Authoii�cd for t..ocal Rep uction <br />Standard Forrn — LLL <br />/ TO BE INCLUDED IN BID PACKAGE <br />BP 15 of 15 <br />