Attachment D
Public Integrity Disclosure Form
CITY OF PALM SPRINGS – PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
(Revised 09 13 18)
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? Yes No
5. Type of Entity
X Corporation Limited Liability Company Partnership Trust Other (please specify)
6. Officers, Directors, Members, Managers , Trustees, Other Fiduc iaries (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 __Michael H. Ingram__________________ X Officer Director Member Manager [name]
General Partner Limited Partner
Other ____________________________________
__Michael A. Ingram ___________________ X Officer Director Member Manager [name] General Partner Limited Partner
Other ____________________________________
____Nathan Carter______________________ X Officer Director Member Manager [name]
General Partner Limited Partner
Other ____________________________________
Pyro Spectaculars, Inc.
3010 N. Ingram Avenue, Springfield , MO 65803
3196 N. Locust Aveune, Rialto, CA 92377
California
CITY OF PALM SPRINGS – PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
(Revised 09 13 18)
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.
Date Signature of Disclosing Party, Printed Name, Title Pyro Spectaculars LLC- 100%, Pyro Spectaculars, Inc.
Matthew Gilfillan, Vice President
5/20/26
Michael H. Ingram Revocable Living Trust 100% Pyro Spectaculars, LLC Michael H. IIngram 100% -Michael H. Ingram Revocable Living Trust
JC