Development Services Department
Planning Division I Development Processing
CHUILAV
IYOF
CIISTA APPLICATION APPENDIX B Disclosure
Statement Pursuant
to CityCouncilPolicy 101- 01, priorto anyactionon a matterthat requiresdiscretionaryaction by theCity Council, Planning Commissionor otherofficial legislativebody of theCity, a statementof disclosureof certainownerships, financial interest, payments, and campaigncontributionsmust be filed. The followinginformation must be disclosed: 1.
List the namesof all personshaving a financialinterest in theprojectthat is thesubjectof theapplication, project or contract (e. g., owner, applicant, contractor, subcontractor, material supplier). M e oryTsipoyirl 'r 2.
If anyperson* identifiedin section1. aboveis a corporationor partnership, list the namesof all individuals with an investmentof $ 2000or morein thebusiness (corporation/partnership) entity. 3.
If anyperson* identifiedin section1. aboveis a non-profitorganizationor trust, list the namesof any personwho is thedirectorof thenon-profit organizationor thenamesof thetrustee, beneficiaryand trustor of the trust. 4.
Please identify every person, including any agents, employees, consultants, or independentcontractors, whom you haveauthorizedto representyou beforethe City in thismatter. Stephen Ott, SB& O Inc. Melory Tsipouria, Georgia Properties, Manager Bettina Grubert, Flair Architects5.
Has any person *identified in 1., 2., 3., or 4., above, or otherwiseassociated with this contract, project or application, had any financialdealings with an official** of theCity of ChulaVista as it relateso thiscontract, project or applicationwithin the past 12 months? Yes No If yes, brieflydescribethe natureof thefinancialinterest the official** may have in thiscontract. Form 4of9
276 Fourth Avenue I ChulaVista California 1 919101 ( 619) 691. 5101 Rev 007. 14
evelopment Services Department
Planning Division I Development Processing
cnY or
CHULA VISTA
Disclosure Statement - Page 2
APPLICATION APPENDIX B
6. Hasany 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 pas ( 12) months to a current member of the City of Chula Vista Cou cil ? Yes No if yes which council member? TI MCCanrt
7. Hasany person *identified in 1., 2., 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 anything of value, money to retire a legal debt, gift, loan, etc.) Yes NoJ( If
yes, whichofficial** and whatwas the natureof theitem provided? 8.
Has any person *identifiedin 1., 2., 3., or 4., above, or otherwiseassociatedwith this contract, project or application, been a sourceof incomeof $ 59' 0 ormoreto anofficial** of theCity of ChulaVista in thepast ( 12) months? Yes No 7 If
yes, whichofficial** and the natureof theitemprovided? Date 6922 Signature
of Contractor/Applicant Print
or typename of Contractor/Applicant Person
is identifiedas: anyindividual, firm, co - partnership, joint venture, association, social club, fraternal organization, corporation, estate, trust, receiver, syndicate, any othercounty, city, municipality, district, or otherpoliticalsubdivision, or anyothergroup or combinationacting as a unit. official includes, but is notlimitedto: Mayor, Council member, Planning Commissioner, Member of a board, commissionor committeeof theCity, and City employeeor staffmembers. This disclosureStatement must be completedat thetimethe projectapplication, or contract, is submittedto Citystaff for processing, and updatedwithin one weekprior to considerationby legislativebody. Last Updated: March 16, 2010Form
320
50f9
276 Fourth Avenue I ChulaVista I California1 91910I ( 619) 691. 5101 Rev07. 14