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PALP, <br />2g;Z <br />L.3 <br />CITY OF SANTA ANA <br />PROJECT TITLE & NO. # <br />PROPOSAL AND CONTRACT AGREEMENT <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />ConeDlete this form to disclose lobbvine activities nuranant to 41 i i c r r e;I <br />1. Type of Federal Action <br />2 <br />2. Status of Federal Action <br />33.. Report Type: <br />a. Contract <br />A] 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 reort <br />4. Name and Address of Reporting Entity <br />5. If Reporting Entity in No. 4 is Subawardee, Enter Name and <br />uubb <br />Address ofPrhne: <br />BEACMAMMistrict,i known <br />Congressional District i known <br />6. Federal Department/Agency: <br />7. Federal ProgranmNameMescription <br />CFDA Nurnber, If a licable <br />8. Federal Action Number, f knoivn <br />9. Award Amount, y lWown <br />10. a. Name and Address of Lobbying Entity <br />b. Individual Performing Services (rcW#g cxaussif ufromNa <br />(�m6iddr id esn fn9M9 <br />IQq) <br />4WWgf0VnWgAO <br />(attach Continuation <br />Sheets) ifnecess ) <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 />❑ e. deferred <br />value <br />❑ f other, specify <br />14. Brief Description of Services Performed or to be performed and Dates) of Service, including officer(s), employee(s), or member(s) contacted, for <br />Payment indicated in item 11: <br />attach Continuation Sheet(s) i ess <br />15. Continuation Shee s attached: ❑ Yes o <br />16.hmfommadonrogrsleddia0diisfonnis attflmai,edbyTdle31 USCsec im <br />1352TlisdisclmoofkbbyngauMesisanrktigmpw moffadupam <br />Signature__. C. <br />v#dlrelumwwasplaadbyktuabovewhamtetmsadionwasnideoret"d. <br />C. P. B¢t°)A,PHERDENT <br />lila ltilsdisclwmneismegrmedpr antto31U.SC1352. Thisinbunationwillbe <br />Print Name <br />reportedtodrCmgess.ani,imLally"wiUbeavalablebTtbli mTedion <br />kVMsanwdmo&lstofledmemagiieddiselosmshallbea4cdloaadpaaltyof <br />Title <br />artless dmam$10,000"notirmdmam$100,000faeach Rich lailtne <br />(562) 599-5541 SEP - s 2014 <br />Tel hone No. Date <br />Fed®alUse0nly: <br />Audlo izedforLoM Reproduction <br />Standard Form—LLL <br />BP 20 of 26 <br />