ATTACHMENT C
Public Integrity
Disclosure
CITYOFPALMSPRINGS–PUBLICINTEGRITYDISCLOSUREAPPLICANTDISCLOSUREFORM(Revised05/16/19) PUBLIC INTEGRITY DISCLOSURE APPLICANT DISCLOSURE FORM1. Name of Entity2.AddressofEntity(PrinciplePlaceofBusiness)3.LocalorCaliforniaAddress(ifdifferentthan#2)4.StatewhereEntityisRegisteredwithSecretaryofStateIf other than California, is the Entity also registered in California?YesNo5.TypeofEntityCorporationLimited Liability CompanyPartnershipTrustOther (please specify)6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) OfficerDirectorMemberManager [name]General PartnerLimited PartnerOther OfficerDirectorMemberManager [name]General PartnerLimited PartnerOther OfficerDirectorMemberManager [name]General PartnerLimited PartnerOther
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.
01.06.26 Trevor J. Daley, Founder & Chief Executive Officer Trevor J. Daley
100%, Daley Strategies, LLC.