Attachment A
Public Integrity Disclosure Form - Accenture
Public Integrity Disclosure Form - TYLin
TYLin | East Palm Canyon Drive Bridge, RFP 12-04
I-21
1 ATTACHMENT “E”
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
Corporation Limited Liability Company Partnership Trust Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, 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
____________________________________________ Officer Director Member Manager [name]
General Partner Limited Partner
Other _________________________________
[name]
General Partner Limited Partner
Other _________________________________
____________________________________________ Officer Director Member Manager [name]
General Partner Limited Partner
Other _________________________________
T.Y. Lin International
345 California Street, Suite 2400, San Francisco, CA 94104 3633 East Inland Empire Boulevard, Suite 700, Ontario, CA 91764 California
Dan Fitzwilliam, PE
Vice President, Principal-in-Charge
Joseph Smith, PE, CCM
____________________________________________ Officer Director Member Manager Vice President, Project Manager
TYLin | East Palm Canyon Drive Bridge, RFP 12-04
I-222
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
Joseph Smith,
Vice President, Project Manager
April 23, 2026