HomeMy WebLinkAboutItem 2 - Attch 3 - Disclosure StatementD v e 1 o p in e n t S e r v i e s D .e p a r t m e .n t
Planning Division I Development Processing
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CITY , IA VIST4 APPLICATION APPENDIX
[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:
7. 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).
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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 more 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 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
contractors:, whom you ha.ve authorized to represent you before the City in this matter, .
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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 an off icia.l" 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.
Attachment 3
821)
2:76 Fourth Avenue I Chula Vista California 1 91910 1 (619): 691.5101 1 Rev 05.14
D v e I o p m e n t S e r v i e s D e p a r t rn e n t
Planning Division [ Development Process:in.g
MY OF
HULA VISTA APPLICATION APPENDIX
Disclosure Statement _ Page 2
6. Has any person *identified in 1., 2., 1, or 4., above,: or otherwise associated with this contract, project
or application, made a campaign contribution of more than $250 within the past (12) .mo:nths t /a
current member of the City of Chula Vista Council ? Yes No
if yes which council member?
i. Ha.s a.ny person *'identified in 1., 1, 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 a ything 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 $500. or more to an official ** of the City of Chula Vista in the
past (12) rnonths? Yes No
If yes, which official ** and the nature of the item provided?
Date 01 i
.Signature of Contra ctor /A plicant
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Print or type name of Contractor /App:licant
Person is identified as- any individual, firm,, co- partnership, joint venture, association, social club,
fraternal organization, corporation, estate, trust, receiver, syndicate, any other county, city, municipality,
district, or other political subdivision, or any otherF: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
Form
32a
276 Fourth Avenue ( Chula Vista California 1 91910 1 (619) .691.5101 ReY 65.14