City of Glendale DISCLOSURE - CAMPAIGN FINANCE ORDINANCE A contractor must provide the information listed below when: A subcontractor must provide the information listed below when: The City Contract has a total anticipated or actual value of $50,000 or more; orThe subcontract through a City Contract has a total anticipated or actual valueof $25,000 or more; orA combination or series of City Contracts have a value of $50,000 or more.A combination or series of subcontracts, for the same or different projects,have an aggregate value of $25,000 ormore. Information that must be disclosed: Name of the person, entity, or organization (i.e., the Contractor or Subcontractor) Name of the Chief Executive Officer/PresidentChief Operating OfficerChief Financial OfficerChairpersonAll members of the Board of DirectorsAll persons who own more than 10% of the person, entity, or organizationName of any campaign committee owned or controlled by the person, entity, or organizationPlease complete the following disclosure form: Contractor(s)*:NameAddressFull Name TitleBusiness Address City StateZipChairperson Chief Executive Officer / PresidentChief Operating Officer Chief Financial Officer Board of Directors More than 10% interest owner *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 persons,entitys, or organizations Board of Directors, its Chairperson, Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, any person with anownership interest 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.
Rev. 6/7/12 J:\FILES\DOCFILES\ORD\CAMPAIGN CONTRIBUTION\DISCLOSURE FORM CONTRACTOR 6-7-12.doc Subcontractor(s)**:NameAddressFull Name TitleBusiness Address City StateZipChairperson Chief Executive Officer / PresidentChief 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 contractor. Subcontractor includes any member of that persons, entitys, or organizations Board of Directors, its Chairperson, Chief Executive Officer, Chief Financial Officer, Chief Operating 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 owned or controlled by that person, entity, or organization. Above please disclose these persons name and business address. Campaign Committee owned or controlled by: TitleBusiness Address City StateZipCERTIFICATIONOn behalf of the above-named Contractor Subcontractor: I acknowledge that I have a continuing obligation to update this disclosure form if I substitute or if I select additional architects, designprofessionals, contractors, or subcontractors within ten (10) days of the selection or change; andI 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; andI 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: