HomeMy WebLinkAboutItem 3 - Attachment 4 - Disclosure StatementP e v e( a p m e n t S e r v i c e s n p p a r rri e n
Plannfng Division f 0eve,fopfent Proces.s'fn9
CITY Of
;vHilLAVISTA APPi.iCRT[ON APP ND1X f3'
)3isclo U're. Statement:
Putsisabt tb City Cnu.ftcti Policy 1 Q7-fl7, pribr to any:actiori on :a matter that ,reqorEs cl.l$ck °Ci,ohary actioq by tfie, City
counclt Planfii g Cam,missii� n ar otl r ofiicNI legislative i5o;dy of the iYy,'a statet7jent of discitsstire oftertai
awne .rsitips,ffnaraciai.intrest_ p. ayrrieits; a4ticaijnp�ign,: contributics. mustoefilecJ'. 7hefQltoWincirlf6rnrationmust
be disclosed.:
.. t ist ihe:Yiames of al3 is rso s aviryg firfancial inter st: in tlle.pra ect thai .safe subj�ci ofth a
�?Phcatio pralector e4r tYact e.;g o�v ier, appl "rcaYrt, c:ontra�tor,,sul ;cantsctor, mat�1 u
'-s.pliex },
v
(fairy p rsntr trioYStifle l tii section 1 -a. cx e is e.caiporatlon or p.arCnership, Ifstflie,namLs n .ail
it ciiuld f is W[,iFi ars;tn.vestment,cst bbl ,orinor °tl}e,busf ess.{ arpo`i tfo%) ar)iorshtpj enli..tY,
.;. if; a1)ypn rsci.0 J:.(Mifb�d'iiisection1 abo.Veisa.r] ft pro€' ttorgan 'Eza i'.trO'tF;l,i4 ,h.e:})aIrc of
&fv PefsoftVhp Kthe d Ye tnrtii e f?ori- tali <t�rgai7;zaX.ion of tie names "of the; i rrs> e ; b2nef e ary
and rrus ar afxfi�Trusf
Pte se ldeiitffy ewe:ry ppOom, iJ"gding arty agemsi errsp ogees, cca.rr5u[tants oY iiidepelicE irC.
coritra�to)s;: vv¢1om :ya.0 have ai;tl5ti'r. "(zed t iepY�sartt
04 1 00 r .fjie city 117 :this m#ttY«
Ifas.an e son �idehtiFEed its ., 3, ter: ;.abQve,b,r oti7gtwis ssoc afietf 4vlth this corEt� act i�rvject
br- app } "sc tion h �<�ny finarizial :deaffr.gs with. ah o#{rcfaf* o t}ie Gi�y of .Chula. vista as Krelar &s ko th is
.Cbi 1 YdGt pro ecf of a p Wft.hin past.12 montbh 7 Yes Flo —f
(f yes bre7} des,ri:b :e She ,azure of:the tinaricfaf interest the ofCcal,kk:finayhave in [his contract_.
276 f=ourth Averiife I Chii3a Vista I Caiifornia I 9i 910 1 (616) 691 5701
+off ;o J
Attcachnicnt 4
D e y e l 0 1? m e, t. S e r v i c e s' b e p a r t to e ri t
Planning Division f Development Processing
My OF
CHUiAVISTA APPLICATIQN APPENDIX 8
Disclosure Statewenh Page 2
es,. Has any person. iderstifieci [n 1., car 4:., abOye or otherwise associated with this contract, project
or application; made a eampa gn contr.ibutioh i f "more thj'n SM Within the past (12). mont ss:to a
current member of the Cityof Chula. Vista Council ? Yes No
if yes which counc"il,member'?
7„ Has, any pefson. *ldentified. in.I :, 2.; 3-, or ., " above, or otherwise associated with ibis contract, project
o.r;appl!Wion, provided more"thari �.42o' (d.ran item! ofequivaie tvawu )'to an of vial of the ify,gi
Ciila'ista lte past (T2) months? (fFiis,inci.uc€es any payment that confers a z personal benefit "ari the
recipient, a rehate,or diseuunt [tithe pried of abrhing ofvaluo, money tg Yetii•e a {ecgal debt, gift, loan;
eCe } Yes to
If yes which'offFclal'* a.nd fiatwas tho.nature ofthe Iti nrq provi'dl ,d.?
$,; 1 ia5an ea soniclent�fiod °ire 1,.12;, 3, ar:�i,,, above ,'arotfiel'wtse,assaeiatecl with this e.ontract, project
Yp
of appiica ion, b >e11 a source of income of $5001 or!M_ ore to'an officlai11* cif the City of Chola Vista in the
past (1:2) months? Yes` Na
If Yes, yvh.i:ch off icial** and. the gature ofi to item! provided?
`
Signatur' of Contraaor /Applicant
Printort penatneafConitactorlAjapEicant
P:erson'Fs identified as, any individual, firm, cd- partnership, �oirit venture, associat rrn, social stub,
fraternal oigani ation, corporation, estaie, trust; receivEr, •syndicate`, My'Whet cou"My,, city, rnUnicipali y,
district, or other political svbdivlsia.n, or arty other 1roup or Ohibinatinn.acting as a Unit
44� flfti:cial includes,.6vt is fOt limited to. tvlayar; Council member, Manning Cornrriissioner, Member 'ofa
board, commission or committee, ofthe City, and City employee or "staff tne,mbers -.
ThFs disclosure SLatetnent mi!st be. cnYnpleted at.the tilrrte the project . application, or contract, is submitt ed
to City staff for processing, anti updated within one "vii k prior'to c. o. rs. id. eratio.. n by legislative body.,
Last Updated: March 16, �Oln
Form
APR �
Rev G3.! Ef
276 Fourth Avenue I Chtda Vista California 1 9191a f (r,1 9) 591.5101 r�vz
M