HomeMy WebLinkAboutItem 3 - Attachment 4 - Disclosure StatementD e v e t o p m e n t 5 e r v i c e s D e p a r t m e n t
Planning Division Development Processing
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C:HULA VISTA APPLICATION APPENDIX B
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Disclosure Statement
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Pursuant to City Council Policy 101 -41, prior to any action on a matter that requires discretionary action by the Clty
Council, Planning Commission or other official legislative body of the City, a statement of disclosure of certain
ownerships, financial interest, payments, and campaign contributlons must be filed. The following information must
be disclosed:
1, Llstthe names of all persons having a financial interest in the project that is the subject of the
application, project orcontract (e.g., owner, applicant, contractor, subcontractor, material supplier).
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2. if any person' identified In section 1. above is a corporation or partnership, list the names of all
individuals with an investment of $2000 or snore in the business 'lcorpo ratio nlpartnershipj entity.
3. If 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, beneficlaty
and trustor of the trust.
4, Please identify every person, including any agents, employees, consultants, or independent
contractors, whom you have authorized to represent you before the City in this matter,
5. Has any person *identified In 1., 2., 3., or 4., above, or otherwise associated with this contract, project
or application, had any financial dealings with an official — of the City of Chula Vista as it relates to this
contract, project or application within the past 12 months? Yes No .
If yes, briefly describe the nature of the financial interest the official"* may have In this contract.
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Planning Division I Development Processing
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Disclosure Statement - rage 2
APPLICATION APPENDIX B
6. Has any person *'identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
or application, made a campaign contribution of more than $2511 within the past (12) months to a
current member of the City of Chula Vista Council? Yes No
if yes which council member?
7. Has any person *'identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
or application, provided more than $420 (or an item of equivalent value) to an official* of the City of
Chula Vista in the past (12) months? (This includes any payment that confers a personal benefit on the
recipient, a rebate or discount in the price of nything of value, money to retire a legal debt, gift, loan,
etc.) Yes No
If yes, which official " and what was the nature of the item provided?
8. Has any person *identified in 1., 2., 3., or-4., above, or otherwise associated with this contract, project
or application, been a source of income of $Soo or more to an official" of the City of Chula Vista it) the
past (12) months? Yes No
if yes, which official* and the nature of the item provided?
Date-
/// Slg ature oofrContractor /Applicant
Print or type name of Contractor /Applicant
* Person is identified as: any Individual, firm, co- partnership, joint venture, association, social club,
fraternal organization, corporation, esta-re,-crust, receiver, syndicate, any other county, city, municipality,
district, or other political subdivision, or any other group or combination acting as a unit.
official 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,
* This disclosure Statement must be completed at the time the project application, or contract, is submitted
s to City staff for processing, and updated within one week prior to consideration by legislative body.
Last updated; March 15, 2010
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276 Fourth Avenue i Chula Vista California 1 91910 I (619) 691.5701 Pdv�
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D e v e I o p m. e n t S e r v€ c e s D e p a r t m e n t
Planning Division I Development Processing
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Disclosure Statement - rage 2
APPLICATION APPENDIX B
6. Has any person *'identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
or application, made a campaign contribution of more than $2511 within the past (12) months to a
current member of the City of Chula Vista Council? Yes No
if yes which council member?
7. Has any person *'identified in 1., 2., 3., or 4., above, or otherwise associated with this contract, project
or application, provided more than $420 (or an item of equivalent value) to an official* of the City of
Chula Vista in the past (12) months? (This includes any payment that confers a personal benefit on the
recipient, a rebate or discount in the price of nything of value, money to retire a legal debt, gift, loan,
etc.) Yes No
If yes, which official " and what was the nature of the item provided?
8. Has any person *identified in 1., 2., 3., or-4., above, or otherwise associated with this contract, project
or application, been a source of income of $Soo or more to an official" of the City of Chula Vista it) the
past (12) months? Yes No
if yes, which official* and the nature of the item provided?
Date-
/// Slg ature oofrContractor /Applicant
Print or type name of Contractor /Applicant
* Person is identified as: any Individual, firm, co- partnership, joint venture, association, social club,
fraternal organization, corporation, esta-re,-crust, receiver, syndicate, any other county, city, municipality,
district, or other political subdivision, or any other group or combination acting as a unit.
official 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,
* This disclosure Statement must be completed at the time the project application, or contract, is submitted
s to City staff for processing, and updated within one week prior to consideration by legislative body.
Last updated; March 15, 2010
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App. H
Aev 07.16
276 Fourth Avenue i Chula Vista California 1 91910 I (619) 691.5701 Pdv�
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