423380.1
ATTACHMENT 1
Professional Services Agreement
for Consultant Services Between the
City of Barstow and Jeanette Hayhurst
(Proposed 2025 Agreement)
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Professional Services Agreement
(City of Barstow /Jeanette Hayhurst)
Professional Services Agreement Consultant Services
Approved for use:02/24/2025
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PROFESSIONAL SERVICES AGREEMENT
FOR CONSULTANT SERVICES
(City of Barstow /Jeanette Hayhurst )
1. IDENTIFICATION
This PROFESSIONAL as of
the last signature date indicated below by and between the City of Barstow, a California municipal City , and Jeanette Hayhurst, a sole proprietor (individually, a collectively, the
2. RECITALS
2.1 City has determined that it requires the following professional services from a consultant:
Project.
2.2 Consultant represents that it is fully qualified to perform such professional services by virtue of its experience and the training, education and expertise of its principals and employees. Consultant further represents that it is willing to accept responsibility for performing such services in accordance with the terms and conditions set forth in this Agreement.
2.3 Consultant represents that it has no known relationships with third parties, City Council members, or employees of City which would (1) present a conflict of interest with the rendering of services under this Agreement under Government Code Section 1090, the Political Reform Act (Government Code Section 81000 et seq.), or other applicable law; (2) prevent Consultant from performing the terms of this Agreement, or (3) present a significant risk of the disclosure of confidential information.
2.4 As of the Commencement Date (as defined hereunder), this Agreement supersedes and replaces any and all prior agreements, contracts, understandings, negotiations, and communications, whether written or oral, between the parties relating to the subject matter hereof, including, without limitation, that certain Professional Services Agreement for Consultation Services entered into by and between the Parties that commenced on February 19, 2024. Notwithstanding the foregoing, the parties' rights and remedies with respect to any breach of a prior agreement that occurred prior to the effective date of this Agreement shall survive and remain enforceable in accordance with the terms of such prior agreement.
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NOW, THEREFORE, for and in consideration of the mutual covenants and conditions herein contained, City and Consultant agree as follows:
3. DEFINITIONS
3.1 means such professional services as described in Exhibit A attached hereto and fully incorporated herein by this reference.
3.2 means such compensation rates as are set forth in the fee schedule attached hereto as and fully incorporated herein by this reference. This fee schedule shall remain in effect for the duration of this Agreement unless modified in writing by mutual agreement of the parties.
3.3 means September 1, 2025.
3.4 Termination means August 31, 2026.
3.5 City Chris Heldreth. The Agreement
Administrator shall be the principal point of contact at the City for this project.
3.6 Consultant by City under this Agreement. The Maximum Amount under this Agreement is $74,999.00.
4. CAMPAIGN CONTRIBUTIONS
This Agreement is subject to Government Code section 84308, as amended by Senate Bill 1439 (2022), Senate Bill 1181 (2024), and Senate Bill 1243 (2024). Consultant shall disclose any ittee in an amount of
more than five hundred dollars ($500) made within 12 months preceding the Commencement Date, by Consultant, their agent, or another party affiliated with Consultant. Consultant shall provide a signed copy of the attached Campaign Contribution Disclosure Form to City prior to, or concurrent with, Consultant's execution of this Agreement and no later than the Commencement Date.
5. TERM
The term of this Agreement shall commence at 12:00 a.m. on the Commencement Date and shall terminate at 11:59 p.m. on the Termination Date unless extended for one or more additional one-year periods by written mutual agreement of the parties executed prior to the C#___________
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Professional Services Agreement Consultant Services
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Termination Date of the current term or terminated earlier in accordance with Section 19
6. 6.1
Agreement.
6.2 Consultant shall perform the services identified in the Scope of Services. City shall have the right to request, in writing, changes in the Scope of Services. Any such changes mutually agreed upon by the parties, and any corresponding increase or decrease in compensation, shall be incorporated by written amendment to this Agreement. In no event shall the total compensation and costs payable to Consultant under this Agreement exceed the Maximum Amount unless specifically approved in advance and in writing by
or City Council. Consultant shall notify the City Agreement Administrator, in writing, when fees and expenses incurred under this Agreement have reached eighty percent (80%) of the Maximum Amount. Consultant shall concurrently inform the City Agreement Administrator, in writing,
total expenditures required to complete its current assignments before proceeding, when the remaining work on such assignments would exceed the Maximum Amount.
6.3 Consultant shall obtain and maintain in force a City business license for the duration of this Agreement.
6.4 profession and in a manner reasonably satisfactory to City. Consultant shall comply with all applicable federal, state, and local laws and regulations, including the conflict of interest provisions of Government Code Section 1090 and the Political Reform Act (Government Code Section 81000 et seq.).
6.5 During the term of this Agreement, Consultant shall not perform any work for another person or entity for whom Consultant was not working at the Commencement Date if both (i) such work would require Consultant to abstain from a decision under this Agreement pursuant to a conflict of interest statute and (ii) City
6.6 Consultant represents that it has, or will secure at its own expense, all personnel required to perform the services identified in the Scope of Services. All such services shall be performed by Consultant or under its supervision, and all personnel engaged in the work shall be qualified to perform such services. Jeanette Hayhurst shall be the Consultant Project Administrator and shall have direct C#___________
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No other person shall serve as Consultant Project Administrator without City prior written consent.
6.7 This Agreement covers professional services of a specific and unique nature.
Except as otherwise provided herein, Consultant shall not assign or transfer its interest in this Agreement, delegate its duties under this Agreement, or subcontract any services to be performed without amending this Agreement.
6.8 Consultant shall be responsible to City for all services to be performed under this Agreement. All subconsultants shall be approved by the City Agreement Administrator and their billing rates identified in the Approved Fee Schedule, Exhibit B. City shall pay Consultant for work performed by its subconsultants -up as set
forth in the Approved Fee Schedule, Exhibit B. Consultant shall be liable and accountable for any and all payments, compensation, and federal and state taxes to all subconsultants performing services under this Agreement. City shall not be liable for any payment, compensation, or federal and state taxes for any subconsultants.
6.9 Consultant shall notify the City Agreement Administrator, in writing, of any change in name, ownership, of any subconsultant.
the Agreement as determined by the City within its sole and absolute discretion.
6.10 Consultant shall comply with all prevailing wage laws applicable to this Agreement.
7. COMPENSATION
7.1 City agrees to compensate Consultant for the services provided under this Agreement, and Consultant agrees to accept payment in accordance with the Approved Fee Schedule in full satisfaction for such services.
7.2 Consultant shall submit to City an invoice, on a monthly basis or as otherwise agreed to by the City Agreement Administrator, for services performed pursuant to this Agreement. Each invoice shall identify the Maximum Amount, the services rendered during the billing period, the amount due for the invoice, and the total amount previously invoiced. All labor charges shall be itemized by employee name and classification/position with the firm, the corresponding hourly rate, the hours worked, a description of each labor charge, and the total amount due for labor charges. City shall not withhold applicable taxes or other payroll deductions from payments made to Consultant except as otherwise required by law. Consultant shall C#___________
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include a copy of each subconsultant invoice for which reimbursement is sought in the invoice.
7.3 The parties agree to meet and confer at mutually agreeable times to resolve any disputed amounts contained in an invoice submitted by Consultant.
7.4 Consultant shall not be reimbursed for any expenses incurred for work performed outside the Scope of Services unless prior written approval is given by the City through a fully executed written amendment to this Agreement. Consultant shall not undertake any such work without prior written approval of the City Manager, . 7.5 Notwithstanding any other terms of this Agreement, no payments shall be made to Consultant until City is satisfied that the services are satisfactory.
8. OWNERSHIP OF WRITTEN PRODUCTS
All reports, documents or other written material, and all electronic files, including computer-aided design files, developed by Consultant in the performance of this Agreement (such remain the property of City without restriction or limitation upon its use or dissemination by City except as provided by law. Consultant may take and retain copies of such written products as desired, but no such written products shall be the subject of a copyright application by Consultant.
9. RELATIONSHIP OF PARTIES
9.1 Consultant is, and shall at all times remain as to City, a wholly independent contractor. Consultant shall have no power to incur any debt, obligation, or liability on behalf of City or otherwise to act on behalf of City as an agent. Consultant, its officers, employees, and agents shall not have any power to bind or commit the City to any decision or course of action, and Consultant, its officers, employees and agents shall not represent to any person or party that it or they are acting as agents of the City or that it or they have the power to bind or commit the City. Neither City nor any of its agents shall have control over the conduct of Consultant or any not represent that it is, or that any of its agents or employees are, in any manner employees of City.
9.2 Under no circumstances shall Consultant look to the City as its employer.
Consultant shall not be entitled to any benefits. City makes no representation as to earned California Public Employees Retirement System PERS retirement benefits, if any, and Consultant specifically assumes the responsibility for making C#___________
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such a determination. Consultant shall be responsible for all reports and obligations including, but not limited to: social security taxes, income tax withholding, , and other
applicable federal and state taxes.
10. AGREEMENT ADMINISTRATOR
In performing services under this Agreement, Consultant shall coordinate all contact with City through its City Agreement Administrator. City reserves the right to change this designation upon written notice to Consultant. All services under this Agreement shall be performed at the request of the City Agreement Administrator, who will establish the timetable for completion of services and any interim milestones.
11. INDEMNIFICATION
11.1 The parties agree that City, its officers, agents, employees, and volunteers should, to the fullest extent permitted by law, be protected from any and all loss, injury, other cost arising out of or in any way related to the performance of this Agreement.
Accordingly, the parties intend the provisions of this indemnity provision to be interpreted and construed to provide the City with the fullest protection possible under the law. Consultant acknowledges that City would not enter into this City as set forth herein.
11.2 To the fullest extent permitted by law, Consultant shall indemnify, hold harmless, and when the City requests with respect to a claim provide a deposit for the defense of, and defend City, its officers, agents, employees, and volunteers from and against any and all claims, losses, costs and expenses for any damage due to death or injury to any person, whether physical, emotional, consequential or otherwise, and injury to any property arising out of or in connection with Co recklessness, or willful misconduct or other wrongful acts, errors or omissions of Consultant or any of its officers, employees, servants, agents, or subcontractors, or anyone directly or indirectly employed by either Consultant or its subcontractors, in the performance of this Agreement or its failure to comply with any of its obligations contained in this Agreement, except such loss or damage which is caused by the sole active negligence or willful misconduct of the City. Such costs and expenses shall include City
choice, expert fees, and all other expenses of litigation. Consultant shall not be , or expenses in the event that
it is adjudicated to have been non-negligent.
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11.3 City shall have the right to offset against any compensation due Consultant under this Agreement any amount due City
failure to pay City promptly any indemnification arising under this section of this Agreement and any amount due City
failure either to (i) pay taxes on amounts received pursuant to this Agreement or
11.4 The obligations of Consultant under this section of this Agreement are not limited expressly waives any applicable statutory immunity under such statutes as to City, its officers, agents, employees, and volunteers.
11.5 Consultant agrees to obtain executed indemnity agreements with provisions identical to those set forth in this section of this Agreement from each and every subcontractor or any other person or entity involved by, for, with, or on behalf of Consultant in the performance of this Agreement. If Consultant fails to obtain such indemnity obligations from others, Consultant agrees to indemnify, hold harmless, and defend City, its officers, agents, employees, and volunteers from and against any and all claims, losses, costs, and expenses for any damage due to death or injury to any person and injury to any property resulting from any alleged intentional, reckless, negligent, or otherwise wrongful acts, errors, subcontractors or any other person or entity involved by, for, with or on behalf of Consultant in the performance of this Agreement. Such costs and expenses shall City
11.6 City does not, and shall not, waive any rights that it may possess against Consultant because of the acceptance by City, or the deposit with City, of any insurance policy or certificate required pursuant to this Agreement. This hold harmless and indemnification provision shall apply whether or not any insurance policies apply to a claim, demand, damage, liability, loss, cost or expense.
11.7 In the event that Consultant or any employee, agent, or subcontractor of Consultant providing services under this Agreement claims or is determined by a court of competent jurisdiction or CalPERS to be eligible for enrollment in CalPERS as an employee of the City, Consultant shall indemnify, defend, and hold harmless City for the payment of any employee and/or employer contributions for CalPERS benefits on behalf of Consultant or its employees, agents, or subcontractors, as well as for the payment of any penalties and interest on such contributions, which would otherwise be the responsibility of City.
11.8 Notwithstanding any federal, state, or local policy, rule, regulation, law or ordinance to the contrary, Consultant and any of its employees, agents, and subcontractors providing service under this Agreement shall not qualify for or C#___________
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become entitled to, and hereby agree to waive any claims to, any compensation, benefit, or any incident of employment by City, including but not limited to eligibility to enroll in CalPERS as an employee of City and entitlement to any contribution to be paid by City for employer contribution and/or employee contributions for CalPERS benefits.
12. RESERVED
13. MUTUAL COOPERATION
13.1 City shall provide Consultant with all pertinent data, documents, and other requested information as is reasonably available for the proper performance of
13.2 If any claim, action, or proceeding is brought against City performance in connection with this Agreement, Consultant shall render any reasonable assistance that City may require in the defense of that claim, action, or proceeding.
14. CONFIDENTIALITY
All data, documents, discussion, or other information developed or received by Consultant or provided for performance of this Agreement are deemed confidential and shall not be disclosed by Consultant without prior written consent by City. City shall grant such consent if disclosure is legally required. Upon request, all City data shall be returned to City upon the termination or expiration of this Agreement. 15. RECORDS AND INSPECTIONS Consultant shall maintain any and all ledgers, books of account, invoices, vouchers, canceled checks, and other records or documents evidencing or relating to charges for services or expenditures and disbursements charged to City under this Agreement for a minimum of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such documents shall be made available for inspection, audit, and/or copying at any time during regular business hours, upon oral or written request of City. City shall further have the right to make transcripts therefrom and to inspect all program data, documents, proceedings, and activities.
In addition, pursuant to Government Code Section 8546.7, if the amount of public funds expended under this Agreement exceeds ten thousand dollars, all such documents and this Agreement shall be subject to the examination and audit of the State Auditor, at the request of City or as part of any audit of City, for a period of three (3) years after final payment under the Agreement.
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Professional Services Agreement
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Professional Services Agreement Consultant Services
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16. PERMITS AND APPROVALS
Consultant shall obtain, at its sole cost and expense, all permits and regulatory approvals to, professional licenses, encroachment permits, and building and safety permits and inspections.
17. NOTICES
Any notices, bills, invoices, or reports required by this Agreement shall be deemed received on: (i) the day of delivery if delivered by hand, facsimile or overnight courier service during City
in the United States mail if delivered by mail, postage prepaid, to the addresses listed below (or to such other addresses as the parties may, from time to time, designate in writing).
If to City:
Chris Heldreth
Community Development Director
City if Barstow
220 E. Mountain View St., Suite A
Barstow, CA 92311
Telephone: (760) 255-5169
Email: [email protected]
If to Consultant:
Jeanette Hayhurst
308 Phyllis Way
Stagecoach, NV 89429
Telephone: (760) 953-8520
Email: [email protected]
With courtesy copy to:
Matthew T. Summers, City Attorney
Colantuono, Highsmith & Whatley, PC
790 E. Colorado Blvd., Suite 850
Pasadena, CA 91101
Telephone: (213) 542-5719
Facsimile: (213) 542-5710
Email: [email protected]
18. SURVIVING COVENANTS
The parties agree that the covenants contained in Section 11, Subsection 13.2, Section 14, and Section 15 of this Agreement shall survive the expiration or termination of this Agreement.
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19. TERMINATION
19.1. City
notice to Consultant. Consultant may terminate this Agreement for any reason on City. Consultant agrees to cease all work
under this Agreement on or before the effective date of any notice of termination.
All City data, documents, objects, materials or other tangible things shall be promptly returned to City upon the termination or expiration of this Agreement.
19.2. If City terminates this Agreement due to no fault or failure of performance by Consultant, then Consultant shall be paid based on the work satisfactorily performed at the time of termination. In no event shall Consultant be entitled to receive more than the Maximum Amount that would be paid to Consultant for the full performance of the services required by this Agreement.
20. GENERAL PROVISIONS
20.1 Consultant shall not delegate, transfer, subcontract, or assign its duties or rights hereunder, either in whole or in part, without City
attempt to do so shall be void and of no effect. City shall not be obligated or liable under this Agreement to any party other than Consultant.
20.2 Masculine or feminine pronouns shall be substituted for the neuter form and vice versa, and the plural shall be substituted for the singular and vice versa, in any place or places herein in which the context requires such substitution(s).
20.3 The waiver by City or Consultant of any breach of any term, covenant or condition herein contained shall not be deemed to be a waiver of any other term, covenant or condition or of any subsequent breach of the same or any other term, covenant or condition herein contained. No term, covenant or condition of this Agreement shall be deemed to have been waived by City or Consultant unless in writing signed by one authorized to bind the party to be charged with the waiver.
20.4 Consultant shall not be liable for any failure to perform if Consultant presents acceptable evidence, in City
beyond the control and without the fault or negligence of Consultant.
20.5 Each right, power, and remedy provided for herein or now or hereafter existing at law, in equity, by statute, or otherwise shall be cumulative and shall be in addition to every other right, power, or remedy provided for herein or now or hereafter existing at law, in equity, by statute, or otherwise. The exercise, the commencement of the exercise, or the forbearance from the exercise by any party of any one or more of such rights, powers, or remedies shall not preclude the simultaneous or C#___________
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later exercise by such party of any or all of such other rights, powers or remedies.
If legal action shall be necessary to enforce any term, covenant or condition contained in this Agreement, the party prevailing in such action, whether or not reduced to judgment, shall be entitled to its reasonable court costs, including any litigation shall be San Bernardino County, California and Consultant hereby consents to jurisdiction in San Bernardino County for purposes of resolving any dispute or enforcing any obligation arising under this Agreement.
20.6 If any term or provision of this Agreement or the application thereof to any person or circumstance shall, to any extent, be invalid or unenforceable, then such term or provision shall be amended to, and solely to the extent necessary to, cure such invalidity or unenforceability, and in its amended form shall be enforceable. In such event, the remainder of this Agreement, or the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby, and each term and provision of this Agreement shall be valid and be enforced to the fullest extent permitted by law.
20.7 This Agreement shall be governed and construed in accordance with the laws of the State of California.
20.8 All documents referenced as exhibits in this Agreement are hereby incorporated into this Agreement. In the event of any material discrepancy between the provisions of this Agreement and those of any document incorporated herein by reference, the provisions of this Agreement shall prevail. This instrument contains the entire Agreement between City and Consultant with respect to the transactions contemplated herein. Except as otherwise provided herein, no other prior oral or written agreements are binding upon the parties. Amendments hereto or deviations herefrom shall be effective and binding only if made in writing and executed on behalf of the City and Consultant.
20.9 Consultant shall not discriminate against any employee or applicant for employment because of race, sex (including pregnancy, childbirth, or related medical condition), creed, national origin, color, disability as defined by law, disabled veteran status, Vietnam veteran status, religion, age (40 and above), medical condition (cancer-related), marital status, ancestry, or sexual orientation.
Consultant shall take affirmative action to ensure that applicants are employed, and that employees are treated during employment without regard to race, sex (including pregnancy, childbirth, or related medical condition), creed, national origin, color, disability as defined by law, disabled veteran status, Vietnam veteran status, religion, age (40 and above), medical condition (cancer-related), marital status, ancestry, or sexual orientation. Such action shall include, but not be limited to, the following: employment, upgrading, demotion, or transfer; recruitment or C#___________
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recruitment advertising; layoff or termination; rates of pay or other forms of compensation; or in terms, conditions or privileges of employment, and selection for training, Consultant agrees to post in conspicuous places, available to employees and applicants for employment, the provisions of this nondiscrimination clause.
20.10 This Agreement shall be binding on successors and assigns of the parties.
20.11 Except as expressly stated herein, there is no intended third-party beneficiary of any right or obligation assumed by the parties.
20.12 The Recitals are incorporated by this reference.
TO EFFECTUATE THIS AGREEMENT, the parties have caused their duly authorized representatives to execute this Agreement as of the last date indicated below:
City
By___________________________ By:_______________________________ Rochelle Clayton, City Manager Jeanette Hayhurst
Date:______________________ Date:_________________________ Attest:
By
Andrea Flores, City Clerk
Date:_______________________
Approved as to form:
By__________________________________
Matthew T. Summers, City Attorney
Date: __________________________
EXHIBIT A
SCOPE OF WORK PROJECT MANAGER
Exhibit A
408902.1
The consulting services described in this Scope of Work are to be provided under the direction of the Barstow City Manager and provided exclusively for what is commonly referred to as the Barstow International Gateway These
services do not extend to any other projects, initiatives, or work requests, whether related or unrelated to the subject matter of engagement as Project Manager for the BIG Project.
Any additional services or work beyond the scope explicitly defined in this document will require a separate written agreement and scope of work. The City Manager or their designee retains sole The Consultant acknowledges that all recommendations, proposed changes, decisions, scope modifications, and other determinations made by the Consultant in connection with this Project are subject to review and approval by the City Manager or their authorized designee before implementation. The Consultant agrees to coordinate with and seek timely approval from the designated City representative for all Project decisions.
Consistent with the immediately proceeding paragraph and the rest of this Agreement, Consultant will:
1. Represent the city at Project-related meetings both remotely and in-person.
2. Collect, organize, and distribute data amongst City staff, City contractors, subconsultants, and project stakeholders.
3. Interact effectively with local, state, and federal government agencies.
4. Conduct group presentations and provide information to a variety of stakeholders such as local residents, businesses, schools, etc.
5. Work effectively with City contractors, City subcontractors, and City staff, including, without limitation, City Planning, Engineering, and Building Department staff.
6. Communicate with regional governmental agencies including but not limited to: the Local Agency Formation Commission, Lahontan Regional Water Quality Control Board, Mojave Desert Air Quality Management District, Mojave Water Agency, etc.
7. Perform any other project-related duties as needed and requested by the City Manager or their designee.
EXHIBIT B
APPROVED FEE SCHEDULE
Exhibit B
408902.1
Hourly Rate:
$100.00 per hour.
Time Increments: Services shall be billed in 6-minute increments (i.e., 1/10 of an hour). Partial increments are rounded up to the nearest 6-minute block.
Costs:
prior written approval for costs exceeding $100.00.
Fees and Costs Exceeding Maximum Amount or Unrelated to Agreement: City shall not be responsible for payment of any services or costs billed above the Maximum Amount or billed for services performed or costs incurred outside of the scope of this Agreement without prior written
CAMPAIGN CONTRIBUTION DISCLOSURE
PROVISIONS
Cities are subject to the campaign disclosure provisions detailed in Government Code Section 84308. Please carefully read the following information to determine if the provisions apply to you. If you determine that the
provisions are applicable, the Campaign Disclosure Form must be completed and returned to the City with your application. 1. No City councilmember or commissioner shall accept, solicit, or direct a contribution of more than $500 from any party,1 financially interested participant,2 or agent3 while a proceeding is pending or for 12 months subsequent to the date a final decision is rendered by the City. This prohibition commences when your application has been filed, or the proceeding is otherwise initiated.
2. A party to a City proceeding shall disclose on the record of the proceeding any contribution of more than $500 made to any councilmember or commissioner by the party, or agent, during the preceding 12 months. No party to or participant in a City proceeding shall make a contribution of more than $500 to a councilmember or commissioner during the proceeding and for 12 months following the date a final decision is rendered by the City.
No agent to a party or participant shall make a contribution in any amount to a councilmember of commissioner during the proceeding and for 12 months following the date a final decision is rendered by the City.
3. Prior to rendering a decision on a City proceeding, any councilmember or commissioner who received contribution of more than $500 within the preceding 12 months from any party, or agent, to a proceeding shall disclose that fact on the record of the proceeding, and shall be disqualified from participating in the proceeding. However, if any councilmember or
commissioner receives a contribution that otherwise would require disqualification, and returns the contribution within 30 days of making the decision, or knowing about the contribution and the relevant proceeding, whichever comes last, that councilmember or commissioner shall be permitted to
participate in the proceeding. 1 or is the subject of, a proceeding.2 any person who actively supports or opposes a particular decision in a proceeding. 3 connection with a proceeding for compensation who appears before or otherwise communicates with the City for the purpose of influencing the proceeding. If an individual acting as an agent also is acting as an employee or member of a law, architectural, engineering, or consulting firm, or a similar entity or corporation, both the individual and the entity or corporation are agents.
When a closed corporation is a party to a proceeding, the majority shareholder is subject to these provisions.
To determine whether a campaign contribution of more than $500 has been made by you or your agent to a
councilmember or commissioner within the preceding 12
months, all contributions made by you or your agent during that period must be aggregated.
Names of current City councilmembers and commissioners are available If you have questions about
Government Code Section 84308, FPPC regulations, or the Campaign Disclosure Form, please contact the City Clerk.
CAMPAIGN CONTRIBUTION DISCLOSURE
FORM
(a) Document:
Name and address of any party, participant, or agent who has contributed more than $500 to any councilmember or
commissioner within the preceding 12 months:
1. ____________________________________ 2. ____________________________________ 3. ____________________________________ (b) Date and amount of contribution:
Date Amount $
Date Amount $
Date Amount $
(c) Name of councilmember or commissioner to whom
contribution was made:
1. ____________________________________ 2. ____________________________________ 3. ____________________________________ (d) I certify that the above information is provided to the best of my knowledge.
Printed Name
Signature
Date Phone
To be completed by City:
Document No: ______________________________