Attachment 2
CITY OF Applicant/Interested Party
NORWALK Campaign Contribution Disclosure Form
A Connected Community
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 date a final decision from the business or applicant. The Levine Act also requires a member of the contributions totaling more than $250 within the previous 12 months, and for 12 months following 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 about the contributor's relationship with the recipient. as necessary to list contributions made to involved agency officers and provide additional information Contributor
Name/Project:
Date of Contribution
Refunded:
Contribution Recipient Officer/Candidate
Amount Yes No Date of Refund
No contribution made: V
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 Commissioners) 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.
I declare under penalty of perjury that the information which has been included in this Disclosure Form is true and correet.
Presidert 8l2/24
Signature of Applicant Title