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CITY OF SANTA ANA <br />PROJECT NO. 13 -7511 CITYWIDE RESIDENTIAL STREET REPAIR - PHASE 17 <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this form to disclose lobbvin : activities pursuant to 31 U.S,C_ 1352 <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 last report <br />4. Name and Address of Reporting Entity <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Narnc and <br />Address of Prime: <br />❑ Prime ❑ Subwardee <br />Tier , If known <br />Congressional District, i 'krww , <br />Cornressional District, if known <br />6. Federal Department/Agency: <br />_ <br />7. Federal Program Name/Description <br />CFDA Number, If applicable <br />8. Federal Action Number, ifknown <br />9. Award Amount, ifknown <br />10. a. Name and Address of Lobbying Entity <br />b. Individual Performing Services (mchidmg acklty& Wc rmtfivm No. <br />(okilurL,.al,lcoCnrm fuai,M/) <br />ILl) <br />(lastname,fostnww,Ml) <br />attach Continuation <br />Sheet(s) if necessary) <br />11. Amount of Payment (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. Form of Payment (check all that apply): <br />❑ a. cash <br />❑ d. contingent fee <br />❑ b. in-kind; specify: nature <br />❑ c. deferred <br />value <br />❑ f. other, specil <br />14. Brief; Description of Services Perfomred 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 Conk'mtatiun Sheets) ijnecessa <br />15. Continuation Shee s attached: ❑ Yes ❑ No <br />16. hilburnatiorriapesbifibroughthis furnisauthonzedbyTitle31USCSectiari <br />CK <br />1 352.T lm( isJm= oflobbyingadpitiesisamataialrgxckntudonofWupm <br />Signature <br />winchrch&u waspbwdbytheticrk =whaithehmmwmw,sniadeciuheed <br />-nl <br />—T 1 <br />E5 <br />into. sdiselosi =kiu#Wptmdntto3lUSC1352 Thisinbunationwillbe <br />Print Name %R)E� \ V\.j' <br />reportedtolbeConpm,, alu- aruu& yandwillbeavdklefr%pubfichToction. <br />;°-y <br />Anypo,3 o�iwtrofw6 ,tofiletlacmgtmeddsolosrnesbdbes edtoad0p=hyof <br />Title `�(<?c,l(� <br />notl essdia n$1 0, 000adnotmoiethan$100,0001breachsuchfiuturc <br />�-Z'7jate <br />Telephone No. <br />Federal Use Only. <br />Au,"onzecl "s Local Reproduction <br />SC ndardFonn —LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 24 of 30 <br />