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CITY OF SANTA ANA <br />PROJECT NO. 12 -6758: TRAFFIC SIGNAL INSTALLATION ON FAIRVIEW ST & EDNA DR <br />PROJECT NO. 12 -6759: TRAFFIC SIGNAL MODIFICATION ON MCFADDEN AVE & EUCLID <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 <br />1. Type of Federal Action <br />2. Status of Federal Action <br />3. Report T <br />❑ a. Contract <br />❑ a Bid/offer /application <br />❑ a. ' 'tial <br />b. Grant <br />b. initial award <br />material change <br />c. Corporate Agreement <br />c, post -award <br />d. Ban <br />For rial Change only: <br />e. Loan Guarantee <br />Y quarter <br />f. Loan Insurance <br />of last report <br />4. Name and Address of Reporting Entity <br />5. If Reporting Enti in o. s Subawardee, Enter Name and <br />Address of Prime: ' <br />❑ Prime ❑ Subwardee <br />Tier , If known <br />Congressional District, i known <br />Con n istrict, i known <br />6. Federal Department/Agency: <br />7. Federal Pro Name/Description <br />CFDA Number, If applicable <br />8. Federal Action Number, l'known <br />unt, if known <br />10. a. Name and Address of Lobbying Entity erfomring Services (nr *b a"m if furnNo. <br />Fs) <br />n ' o <br />11. Amount of Payment (check all that apply): <br />13. Type of Payment (check all that apply) <br />$ ❑ Actual ❑ Plann <br />❑ a. retainer <br />❑ b. one -time fee <br />❑ c. commission <br />12. Form of Payment (check all that apply): f <br />❑ a. cash <br />❑ d. contingent fee <br />❑ b. in -kind; specify: nature <br />❑ e. deferred <br />❑ f. other, specify <br />14. Brief Description of Services Perfo r to 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 Sheet (s) if recess <br />15. Continuation Sh s attached: El — <br />16. Infonrriimwquestedthnx >ghthisfam' a dhoriwdbyT*31USCSeclian <br />1352. Thisd�sckunoflobbying ' " rsam&nalrepresaftonoffactupon <br />Si <br />whichreliarcewaspbcodbythetier whmthetmsacbmwasrnadecratmed <br />irm. Thisdisclosureisrequired to31U.S.C. 1352. Thisir&nmtiaawillbe <br />Print Nara e L S <br />vWtedlotheCongress axlw> robe available for publicinspecdorr. <br />�— <br />S' <br />Arrypasmv&fa&tofilethe disclosrn4Abe wbjectto add p=4of <br />Title jLnQ T 0` <br />notlessthan$IO,000arIn than $100,000foreachsuchfaltue <br />it <br />Tele hone No. ate <br />�FedaalUse Only: <br />Authorized for Local Reproduction <br />Standard Form— LLL <br />/ TO BE INCLUDED IN BID PACKAGE <br />BP 24 of 30 <br />