HomeMy WebLinkAboutItem 3 - Attch 3 - Disclosure StatementD v e t ,o p rn e n t S e r v i :e s D e p a r t m e 'n t.
Planning Division Development Processing
CHY OF
CHUIA VISTA APPLICATION APPENDIX B .
Disclosure Statement
Puxsua.nt 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 +.clisclosed:
11. List the names of all persons having a financial interest in the project that is the subject of the
application, project or contract (.e:g., owner, appllcant; contractor, subcontractor, material supplier).
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If any persoWl identified in section L. above is a corporation or partnership, list the names of all
individuals with an investment of $2000 or rno:re in the business (corporation /partnership) entity,
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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 no:n- profit .organization or the names of the trustee, beneficiary
and trustor of the trust.
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4. Please identify every person, including any agents, employees, consulta:nt:s, or independent
contractors, whom you have authorized to represent you before the City in this matter.
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5:. Has any person *identified. in. L, 2,, 3., or 4;, above, or :otherwise assq.ciated with this .cotttract,: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 1.2 months.? Yes: No g
If yes,: briefly describe the nature of the financial interest the official ** may have in this .contract..
Aftachment 3
4.00 276 .Fourth Avenue 1 Chula vista California 1 91910 1 (6191.:6.91,51c
.D ` v e i o p rn e n. t S e r v i e s D e p a r t m e n t
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Planning Division i Development Processing
GW OF
CHUTA VRA APPLICATION APPENDIX
Disclosure 'Statemen.t - Page 2
6i Has arty person - identified i61:, 2;, 3., or 4., above, o:r otherwise assoc'i:ate:d with this contract, project
or application., made a cam pal gncontribution of mo.re than $.250. within the past (12} rno'nths't"
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 $420 (or an itern of ecluiva: lent. vaIue) to an off i.cial" of the City of
Chula Vista in the past 0 2) months? (This includes any payment that confers a personal benefit on the
recipient, a rebat.e.or discount in the price of apythmg of value:, money to retire a legal debt, gift, loan,.
etc;) Yes No
lf:yes, which official ** anal what was tie nature of the item provided? fly.
8. Has any person identified in 1., 14, 3:, or 4., above, or otherwise associated with .this contract, project
or application., been a source of income of .$'500 or More to an official" of the City of :Chula Vista in the
past (12) months? Yes No.
If yes, which offici:ala"* and the nature of the item provided!
Date €
Signature ofContractor /A plicant
Print or type name of Contractor /Applicant
:Person is identified as: any individual, firm., co- partnership, joint venture, association, social club,
fraternal organization, corporation, estate, trust;.�eci�iv.er,syndicate; any other county, city, municipality,
district,.gr other political subdivision, o.r 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,. commi'ss'ion or committee of the City; and City employee or staff members.
This disclosure.5taterrient must be com.pleted.at the time the project application;:or contract, is 'subm tted
to City staff for processing, and u.pdate'd within one week prior to consideration by legislative body.
Lost Updated: March 1,6, 201.0
Form
SON Rev 05.14
276 fourth Avenue I Chula Vista I California 1 919 10 1 {619} 6 91:51 01