HomeMy WebLinkAboutItem 3 - Attch 5 - Disclosure StatementATTACHMENT 5
ICI Development Services Department
Planning Division { C3evelopment Processing
CITY of APPLICATION APPENDIX B
CHUTA Vise+
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 roust
be disclosed.
1. 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, applicant, contractor, subcontractor, material supplier).
2. if any person's Identified in section 1, alcove is a corporation or partnership, list the names of all
individuals with an Investment of $20100 or more in the business (corporation /partnership) entity.
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S. if any person* Identified in section I. above is a non- profit organization or trust, list the names of
any person who Is the director of the nonprofit organization or the names of the trustee, benefitlary
and trustor of the trust.
4. Please Identify every person, including any agents, employees, consultants, or independent
contractors, whom yO hoe authorized to represent you before the City In this matter.
s, 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 n official- of the City of Chula Vlsta as it relate to this
contracts project or application within the past 12 months? Yes — No
if yes, briefly describe the nature of the financial Interest the offlcial -'* may have in this contract.
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276 Fourth Avenue I Chula Vista California 1 919 .10 1 (619) 691.5101
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m1/ D e v e l o p m e n t S e r v i c e s D e p a r t m e n t
Planning Division f Development Processing
CITY OF APPLICATION APPENDIX 5
CHUTA VIVA
Disclosure Statement - Page 2
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 $250 within the past (12) months t a
current member ofthe City of Chula Vista Council 7 Yes No
if yes which council member?
7. Has any person 4dentified in % 2., 3., or 4., above, or otherwise associated with this contract, project
or application, provided more than $420 (or an Item of equivalent rt hat e)to
confers a official" of the
benefit City
the
Chula Vista In the post (12) months? (This includes any payment
recipient, a rebate or discopnt in the price of an thing 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?
B. Has any person * Identifled In 1,, 2., 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 K
If yes, which official" and the nature of the Item provided?
Date p, -
Signature of Contractor /Applicant
t
Print or type name of Contractor /Applicant
Person Is identified as: any individual, firm, Gsr- partnership,joint venture, association, social club,
fraternal organization, corporation, estate, trust, receiver, syndicate, any other county, city, municipality,
district, or other political subdivislon, 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
to City staff for processing, and updated within one week prior to consideration by legislative body.
Last Updated: March 16, 2010
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276 Fourth Avenue t Chula Vista callfornia 9i9TD (5191 691.5101