City of Glendale
DISCLOSURE - CAMPAIGN FINANCE ORDINANCE
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A contractor must provide the information listed below when: A subcontractor must provide the information listed below when:
x The City Contract has a total anticipated or actual value of $50,000 or more; or x The subcontract through a City Contract has a total anticipated or actual value of $25,000 or more; or
x A combination or series of City Contracts have a value of $50,000 or more. x A combination or series of subcontracts, for the same or different projects, have an aggregate value of $25,000 or
more. Information that must be disclosed: Ɣ Name of the person, entity, or organization (i.e., the Contractor or Subcontractor) Ɣ Name of the Chief Executive Officer/President
Ɣ Chief Operating Officer
Ɣ Chief Financial Officer
Ɣ Chairperson
Ɣ All members of the Board of Directors
Ɣ All persons who own more than 10% of the person, entity, or organization Ɣ Name of any campaign committee owned or controlled by the person, entity, or organization Please complete the following disclosure form:
Contractor(s)*:
Name Address
Full Name Title Business Address City State Zip
Chairperson
Chief Executive Officer / President
Chief Operating Officer
Chief Financial Officer
Board of Directors
More than 10% interest owner
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* “Contractor” is the person, entity, or organization that is the party, or prospective party, to the contract with the City, ('', or HA or any member of that person’s, entity’s, or organization’s Board of Directors, its Chairperson, Chief Executive Officer, Chief Financial Officer, Chief Operat ing Officer, any person with an ownership interest of more than ten percent (10%) in that person, entity, or organization, and any campaign committee that is o wned or controlled by that person, entity, or organization. Above please disclose these persons’ name and business address. %RDUGRI'LUHFWRUV
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contract awarded to the lowest responsible bidder.
EXHIBIT A
Rev. 6/7/12 J:\FILES\DOCFILES\ORD\CAMPAIGN CONTRIBUTION\DISCLOSURE FORM – CONTRACTOR – 6-7-12.doc Subcontractor(s)**:
Name Address
Full Name Title Business Address City State Zip
Chairperson
Chief Executive Officer / President
Chief Operating Officer
Chief Financial Officer
Board of Directors
More than 10% interest owner
** “Subcontractor” is the person, entity, or organization that has entered into a contract for the performance of all or a portion of the work undertaken under an agreement with an architect, design professional, engineer, or general or prime contract, usually by a general or prime contrac tor. Subcontractor includes any member of that person’s, entity’s, or organization’s Board of Directors, its Chairperson, Chief Executive Officer, Chief Financ ial Officer, Chief Operating Officer, any person with an ownership intere st of more than ten percent (10%) in that person, entity, or organization, and any campaign committee that is owned or controlled by that person, entity, or organization. Above please disclose these persons’ name and business address.
Campaign Committee owned or controlled by:
Title Business Address City State Zip
CERTIFICATION
On behalf of the above-named Contractor Subcontractor:
x I acknowledge that I have a continuing obligation to update this disclosure form if I substitute ʊ or if I select additional ʊ architects, design professionals, contractors, or subcontractors within ten (10) days of the selection or change; and x I hereby certify that:
I have identified all persons for which the Ordinance requires disclosure; The information in this disclosure form (and any attachment to this form) is true, accurate, correct, and complete; and I have been legally authorized to submit this disclosure form.
In total, this disclosure form (including attachments) is pages.
Executed on: , 20 , at: , California.
Signature: Print Full Name:
Address:
Phone Number: E-mail Address:
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