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/c:r~~ NORWALK
A Connoctod Community
Applicant/Interested Party
Campaign Contribution Disclosure Form
Land use, entitlements, licenses, permits, f ranchlses, contracts (excluding labor and competitively bid contracts)
California Government Code Section 84308, commonly referred to as the HLevlne Act," prohibits any Norwalk City Council Member or Planning Commissioner (if they are running for City Council) from psrtlclpatlng In any action related to a contract or application if he or she receives any po/it/cal contributions totaling more than $250 within the previous 12 months, and for 12 months following the date a final decision from the business or applicant. The Levine Act also requires a member of the Official who has received such a contribution to dl&ctose the contribution on the record of the proceeding.
Contribution Disclosure
Please list all contributions in excess of $250 (either as a single payment or in aggregate) made within the past 12 months to officers of the agency involved in the above-mentioned type of proceeding by any parties (applicants) or their agents or representatives, including corporations, limited liability companies (LLCs), or other business entities and principals thereof. You may attach additional pages as necessary to list contributions made to Involved agency officers and provide additional information about the contributor's relationship with the recipient.
Cor,tribllltor Name: TRIO Community Meals
Dote of
Comtribution Recioient Officer /Candidate
No oootribufion made: It/ I
Contribution Refunded:
Amount Yes No Dote of Ref.und
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Pra~ding contributions to candidates does not preoJude the City Council from awarding a contract or approving an applical:ion or any subsequent action. It does, however, preolude the identified City Cooncil Member!Planning Commi$$ioner(s) from partioJpating In any actions related lo your proposal I or appf,catJon. Additionally, this intormation must be updated if contributions e~ceed $250, and no less than 45 days before any agency consideration of an Item In wh1ch you or your company is engaged v.ith the City..
f dedare under penaUy of perjury that the information which has been incfuded in this Disciosure Form is true ~nd cor ct.
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Signature of Applicant