CITY OF CHULA VISTA DISCLOSURE STATEMENT
Pursuant to Council Policy 101-01, prior to any action upon matters that will require discretionary action List the names of all persons having a financial interest in the property that is the subject of the application or the contract, e.g., owner, applicant, contractor, subcontractor, material supplier.
Ray C Samuelson
If any person* identified pursuant to item one (1) above is a corporation or partnership, list the (corporation/partnership) entity. names of all individuals with a two thousand dollars ($2,000) investment in the business Ray C Samuelson
If any person* identified pursuant to item one (1) above is a non-profit organization or trust, list the names of any person serving as director of the non-profit organization or as trustee or beneficiary or trustor of the trust.
None
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contractors you have assigned to represent you before the City in this matter. Please identify every person, including any agents, employees, consultants, or independent None
Has any person* associated with this contract had any financial dealings with an official** of the City as it relates to this contract within the past twelve (12) months? Yes No X 40 Q:1_Projects|GGV0254 - Shelter Onsite\Bid PackagelParts|GGV0254 Bid Package.docx Rev. 2/15/2022
If Yes, briefly describe the nature of the financial interest the official** may have in this contract.
Have you made a contribution of more than two hundred fifty dollars ($250) within the past twelve (12) months to a current member of the Chula Vista City Council? No X Yes_ _If yes, which Council member?
Have you provided more than three hundred forty dollars ($340), or an item of equivalent value, to an official** of the City in the past twelve (12) months? (This includes being a source of income, money to retire a legal debt, gift, loan, etc.) Yes _ No X If Yes, which official** and what was the nature of item provided? Date:_May 18, 2022
Signature of Contractor/Applicant
Western Rim Constructors, Inc. Ray C Samuelson
Name of Company, Firm or Entity Print or type name of Contractor/Applicant President, Secretary and Treasurere
Title
*
Person is defined as: any individual, firm, co-partnership, joint venture, association, social club, raternal organization, corporation, estate, trust, receiver, syndicate, any other county, city, municipality, district, or other political subdivision, or any other group or combination acting as **
Official includes, but is not limited to: Mayor, Council member, Planning Commissioner, Member of a board, commission, or committee of the City, employee, or staff members. 41 Q: _ProjectsIGGV0254 - Shelter Onsite Bid Package/PartsIGGV0254 Bid Package.docx Rev. 2/15/2022