ATTACHMENT B
PUBLIC INTEGRITY BUSINESS DISCLOSURE
PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principal 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, Membe rs, Managers, Tru stees, O ther F iduciaries (please specify) Note: If any response is not a natural pe rson, please identify all off icers, directors, members, managers and other fiduciaries for the member, manager, trust, or other entity
________________________ Officer Director Member Manager [name] General Partner Limited Partner
Other ___________________________
_______________________________ Officer Director Member Manager [ name] General Partner Limited Partner
Other __________________________
________________________________ Officer Director Member Manager [name] General Partner Limited Partner
Other __________________________
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 i n entity
and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER T HE LAWS OF T HE STA TE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Disclosing Party, Printed Name, Title
Date
City of Palm Springs, CA.
Business Disclosure Supplementary Instructions
In an effort to ensure we capture the required business entity information in accordance with the attached instructions, we prov ide you these supplementa ry instructions to clearly identif y the required information, and the format the information should be provided.
If you, as the applicant, are a business entity (i.e. a corporation or limited liability company), and it is also co mprised of other business entities as i ts members or having a financial interest, all other such bu siness entities must als o be disclosed, including those entities o ther business entities, if any.
Ultimately, th e City’s disclosure document (at tached) requires a listing identif ying all n atural persons having any financial interest over 5% of the business entities (and any other b usiness entities comprising your business entity).
As an example, Applicant is: Acme Brothers, Inc., a California corporation, whose officers are:
John Doe, Jill Doe, and Jay Doe, which i s owned 50% by Acme B rothers, LLC, a Cal ifornia limited liabilit y co mpany, and John Doe (25% inte rest) and Jill Doe (25% i nterest). Acme Brothers, LLC, is managed by Acme Brothers 2, Inc ., a Califo rnia corporation, whose officers are: George Doe, Bill Doe, and Jane Doe, which is owned 100% by Ac me Brothers 2, LLC, a California limited liability comp any, which is managed by George Doe, with G eorge Doe and Jane Doe having 50% interest each.
The full business entity disclosure in this example would resemble the following:
1. Acme Brothers, Inc., a California corporation
a. Officers: John Doe, Jill Doe, and Jay Doe
b. Ownership:
i. 50% Acme Brothers, LLC, a California limited liability company ii. 25% John Doe
iii. 25% Jill Doe
2. Acme Brothers, LLC, a California limited liability company a. Managers: Acme Brothers 2, Inc., a California corporation b. Ownership: 100% Acme Brothers 2, Inc., a California corporation
3. Acme Brothers 2, Inc., a California corporation
a. Officers: George Doe, Bill Doe, and Jane Doe
b. Ownership: 100% Acme Brothers 2, LLC, a California limited liability company
4. Acme Brothers 2, LLC, a California limited liability company a. Managers: George Doe
b. Ownership:
i. 50%