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CITY OF SANTA ANA <br />PROJECT 13 -7516: MADISON PARK COMMUNITY GARDEN AND BASKETBALL COURT <br />PROJECT 10 -7564: GARFIELD STREET AT BROWN STREET PARKING LOT EXTENSION <br />PROJECT 13 -7512: MABURY PARK SECURITY LIGHTING <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />Complete this fort to disclose lobbvim activities nursuant to 31 U.S.C. 1352 999 <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 Name and <br />Address of Prime: <br />❑ Prime ❑ Subwardee <br />Tier __,Ifknown <br />Con essional District, i known <br />Congressional District, i known <br />6. Federal Department/Agency: <br />7. Federal Program Name/Description <br />CFDANurnber,Ifapplicable <br />8. Federal Action Number, iflmomn <br />9. Award Amount, f1moivn <br />10. a. Name and Address of Lobbying Entity <br />b. Individual Performing Services ackbewfi d*mntfromN¢ <br />Uir ed,1,Wwugfi',%A4 <br />I" <br />(lasarnar' ftistremg MP <br />(attach Continuation <br />Sheet (s) if necessary) <br />_ <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. Fonn of Payment (check all dial apply): <br />❑ a. cash <br />❑ d. contingent fee <br />❑ b. in -kind; specify: nature <br />❑ e. deferred <br />value <br />❑ f. other, specify <br />14. Brief Description of Services Performed or to be performed and Date(s) of Service, including officer(s), employee(s), or member(s) contacted, far <br />Payment indicated in item 11: <br />attach Continuation Sheet s) if necessary) <br />15. Continuation Shee f s attached: ❑ Yes ❑ No <br />16. hdbmietionrequesbdlltmugh4risfotmisaulltoaizedbyTide31 USCSation <br />1352. Thisdiselosmoflobhyi aoMtlesisamataUvgx icatoffactupon <br />Signature _ <br />which mlivxe was placed by the tier above whin thehansaction was made or entc[W <br />NJ <br />into. T hisdisckstueisregttitdpursusnrtto3lU .S.C.1352. Thisinfronaionwillbe <br />Print Name__ <br />reporbedtotheCongress semi - annually" mill be availableforpublicitvixdiat. <br />Any person who fails0file& required disclosure shall besubjedioaavil Penalty of <br />Title <br />trot less dm $10,000 aid notmae than $100,000 for each such failure. <br />Tele hone No. Date <br />Federal UseOnly: <br />Authonzed for Local Reprodudion <br />Standurd Form —LLL <br />TO BE INCLUDED IN BID PACKAGE <br />BP 27 of 33 <br />