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<br />Agreement#W7-GJC-10 <br />City of Santa Ana <br /> <br /> amPle e IS arm a ISC ase ac IVllIes pursuant to 31 U.S.C 1352 <br />1. Type of Federal Actions: 2. Status of Federal Actions: 3. Report Type: <br /> a. contract a. bid/offer/application a. initial filing <br /> b. grant b. initial award b. materiai change <br /> c. cooperative agreement c. post-award <br /> d. loan For materiai change only: <br /> e. loan guarantee Year: <br /> f. loan insurance NOT APPLICABLE Quarter: <br /> Date of last report: <br />4. Name and Address of Reporting Entity 5. If Reporting Entity in No.4 is a Subawardee: <br /> Prime Subawardee Enter Name and Address of Prime: <br /> Tier if known <br /> Congressional District, if known: <br /> Con~ressional District, if known: <br />6. Federal Department! Agency: 7. Federal Program Name/Description <br />8. Federal Action Number, if known: g. Award Amount, if known: <br /> $ <br />10a. Name and Address of Lobbying Entity 10b. Individual Performing Services <br /> (if individual, iast name, first name, MI): (inciuding address if different from No. 10a) <br /> (last name, first name, Mi): <br />(attach Continuation Sheets SF-LLL-A, if necessarv) <br />11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply) <br /> a. retainer <br />$ Actual Planned b. one-time free <br />12. Form of Payment (check all that apply): c. commission <br /> a. cash d. contingent fee <br /> b. in-kind: specify: e. deferred <br /> nature: f. other specify: <br /> value: <br />14. Enter Description of Services performed or to be Performed and date(s) of Service, including officer(s), employee(s), or Member(s) <br /> contacted, for Payment indicated on item 11: <br />15. Continuation sheet(s) SF-LLL-A attached: DYes DN61 /I~ <br />16. Information requested through this form authorized by Title ~. j/.lt.(.~. <br />31 U.S.C. Section 1352. This disclosure of lobbying activities ts a Signature: - <br />material representation of fact upon which reliance was placed by the Print Name: David N. Ream <br />tier above when this transaction was made or entered into. This <br />disclosure is required pursuant to 31 U.S.C. 1352. Thts information Title: City Manager <br />will be reported to the Congress semiannualiy and will be available for Telephone No: <br />public inspection. An person who fails to file the required disclosure <br />shall be subject to a civil penalty of not less than $10,000 and not Date: October 7, 2009 <br />more than $100 000 for each such failure. <br /> <br />DISCLOSURE OF LOBBYING ACTIVITIES <br />C I t thO ~ t d' if" <br /> <br />W1A Cost Reimbursement Agreement- Green Jobs Corps <br /> <br />Exhibit H- Page 2 of 3 <br />