Applicant/Interested Party
Campaign Contribution Disclosure Form
Land use, entitlements, licenses, permits, franchises, contracts
(excluding labor and competitively bid contracts)
California Government Code Section 84308
,
commonly referred to as the "Levine Act," prohibits any Norwalk
City Council Member
or Planning Commissioner (if they are running for City Council) from
participating in any action related to a contract
or application
if he or she receives any political
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 disclose 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 a
bout the contributor's relationship with the recipient.
Contributor
Name
/Project
:
Date of
Contribution
Recipient Officer/Candidate
Contribution
Amount
Refunded:
Date of Refund
Yes
No
No contribution made:
I declare under penalty of perjury that the information which has been included in this Disclosure Form is true and correct
.
_____________________________
___
__________________________
______
________
Signature of
Applicant
Title
Date
Providing
contributions to candidates
does not preclude the City Council from awarding a contract or approving an application or any subsequent action. It does ,
however, preclude the identified City
Council Member
/Planning Commissioner
(s) from participating in any actions related to your proposal or application. Additionally, this information
must be updated
if contributions exceed $250, and no less
than 45 days before any agency consideration of an item in which you or your company is engaged with the City.
Chief Operating Officer
✔