HomeMy WebLinkAbout02-27-2013 PC Item 1 Attch 6ATTACHMENT 6
OWNERSHIP DISCLOSURE FORM
ATTACHMENT 6
t`�rrll Development Services Department
Planning Division ( Development Processing
MY of
CHULAVll A APPLICATION APPENDIX B
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Disclosure Statement
Pursuant to City Council Policy 101 -01, prior to any action on a matter that requires discretionary action by the City
Council, Planning Commission or other official legislative body of the City, a statement of disclosure of certain
ownerships financial interest, payments, and campaign contributions must be filed, The following information must
be disclosed:
1.
2.
3.
4.
5.
ist the names of all persons having a financial interest in the project that is the subject of the
pplication, project or contract (e.g., owner, applicant, contractor, subcontractor, material supplier),
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f any person* identified in section 1, above is a corporation or partnership, list the names of all
ndividuals with an investment of $2000 or more in the business (corporation /partnership) entity.
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f any person* identified in section 1. above is a non - profit organization or trust, list the names of
any person who is the director of the non - profit organization or the names of the trustee, beneficiary
and trustor of the trust.
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Please identify.every person, including any agents, employees, consultants, or independent
ontractors, whom you have authorized to represent you before the City in this matter.
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as any person *identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
r application, had any financial dealings with an official ** of the City of Chula Vista as it relates to this
ontract, project or application within the past 12 months? Yes No
yes, briefly describe the nature of the financial interest the official ** may have in this contract.
276 Fourth Avenue I Chula Vista I California I 91910 I (619) 691.5101
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CHULA V61A
Development Se.r.vices De.pa.rtme,nt
Planning Division I Development Processing
Disclosure Statement - Page 2
APPLICATION APPENDIX B
6. las any person *identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
r application, made a campaign contribution of more than $250 within the past (12) months to a
urrent member of the City of Chula Vista Council ? Yes No t�
f yes which council member?
7. ias any person *identified in:1., 2., 3., or 4., above, or otherwise associated with this contract, project
r application, provided more than $420 (or an item of equivalent value) to an official ** of the City of
hula Vista in the past (12) months? (This includes any payment that confers a personal benefit on the
ecipient, a rebate or discount in the price of anything of value, money to retire a legal debt, gift, loan,
etc.) Yes No_tz
8.
f yes, which official ** and what was the nature of the item provided?
as any person *identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
r application, been a source of income of $500 or more to an official ** of the City of Chula Vista in the
ast (12) months? Yes No /
yes, which official ** and the nature of the item provided?
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Print or type name of Contractor /Applicant
lerson is identified as: any individual, firm, co- partnership, joint venture, association, social club,
raternal organization, corporation, estate, trust, receiver, syndicate, any other county, city, municipality,
istrict, or other political subdivision, or any other group or combination acting as a unit.
** fficial includes, but is not limited to: Mayor, Council member, Planning Commissioner, Member of a
board, commission or committee of the City, and City employee or staff members,
* ** his disclosure Statement must be completed at the time the project application, or contract, is submitted
o City staff for processing, and updated within one week prior to consideration by legislative body.
Last Updated: March 16, 2010
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Form
App. B
Rev 03.10
276 Fourth Avenue I Chula Vista I California I 91910 (619) 691.5101 ryvZ