ATTACHMENT B
Public Integrity Disclosure Form
CITY OF PALM SPRINGS – PUBLIC INTEGRITY
DISCLOSURE
APPLICANT DISCLOSURE FORM
(Revised 05/16/19)
PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principle Place of Business)
3. Local or California Address (if different than #2)
4. State where Entity is Registered with Secretary of State If other than California, is the Entity also registered in California? F Yes F No
5. Type of Entity
F Corporation F Limited Liability Company F Partnership F Trust F Other (please specify)
6. Officers, Directors, Members, Managers, Trus tees, Other Fiduciaries (please specify) Note:
If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust or other entity F Officer F Director F Member F Manager
[name]
F General Partner F Limited Partner
F Other
F Officer F Director F Member F Manager
[name]
F General Partner F Limited Partner
F Other
F Officer F Director F Member F Manager
[name]
F General Partner F Limited Partner
F Other
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7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity
EXAMPLE
JANE DOE
[name of owner/investor]
50%, ABC COMPANY, Inc.
[percentage of beneficial interest in entity
and name of entity]
A.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
B.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
C.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
D.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
E.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Disclosing Party, Printed Name, Title Date
PENALTIES
Falsification of information or failure to report information required to be reported may subject you to administrative action by the City.
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