ATTACHMENT B
Item 1X - Page 5
Item 1X - Page 6
Who Must File?
CITY OF PALM SPRINGS
PUBLIC INTEGRITY DISCLOSURE
(INSTRUCTIONS FOR APPLICANTS}
Applicants that are NOT a natural person or group of natural people that will be identified on the application, and seek a City approval determined by a vote of City officials. Examples include corporations, limited liability companies, trusts, etc. that seek a City Council approval, or an approval by one of the City's board or commissions.
Why Must I File?
The City of Palm Springs Public Integrity Ordinance advances transparency in municipal government and assists public officials in avoiding conflicts of interest. The City's Public Integrity Ordinance, codified in Chapter 2.60 of the municipal code, reflects the City's interest in ensuring that companies (and other legal entities that are not natural people) doing business in the community are transparent and make disclosure as to their ownership and management, and further that those companies disclose the identity of any person, with an ownership interest worth two thousand dollars ($2,000) or more, who has a material financial relationship with any elected or appointed voting City official, or with the City Manager or City Attorney.
Note: A material financial relationship is a relationship between someone who is an owner/investor in the applicant entity and a voting official (or the City Manager or City Attorney), which relationship includes any of the following:
(1) the owner/investor and the official have done business together during the year prior to the application;
(2) the official has earned income from the owner/investor during the year prior to the filing of the application;
(3) the owner/investor has given the official gifts worlh fifty dollars ($50) or more during the year prior to the filing of the application; or
(4) the official might reasonably be anticipated to gain or lose money or a thing of value, based upon the owner/investor's interest in the applicant entity, in relation to the application's outcome.
When Must I File?
You must file this form with the Office of the City Clerk at the same time when you file your application for a City approval determined by a vote of City officials, whether elected or appointed.
(Revised 09 13 18)
CITY OF PALM SPRINGS - PUBLIC INTEGRITY DISCLOSURE
(INSTRUCTION FOR APPLICANTS)
Item 1X - Page 7
. \_ '
What Must I Disclose?
A. The names of all natural persons who are officers, directors, members, managers, trustees, and other fiduciaries serving trusts or other types of organizations (attorneys, accountants, etc.).
Note: (1) only trusts or other organizations that are not the fiduciaries, (2) if a second entity that is not a natural person serves the applicant entity (e.g., as a member of an applicant LLC), then all officers, directors, members, managers, trustees, etc., of the second entity must be disclosed).
B. The names of persons owning an interest with a value of two thousand dollars ($2,000) or more who have a material financial relationship with an elected or appointed City official who will vote on the applicant's application, or with the City Manager or City Attorney.
PENALTIES
Falsification of information or failure to report information required to be reported may subject you to administrative action by the City.
(Revised 09 13 18)
CITY OF PALM SPRINGS-PUBLIC INTEGRITY DISCLOSURE
(INSTRUCTION FOR APPLICANTS)
Item 1X - Page 8
PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principle Place of Business)
{t(P,) W, eE?N"rvt.y U>i..vlr STt 51)0 r LOS ftt.Jt.GLC~ 41DD4S-
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 Entit also re istered in California? Yes No
5. Type of Entity
gcorporation D Limited Liability Company D Partnership D Trust D Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) te: If any response is not a natural person, please identify all officers, directors , embers, managers and other fiduciaries for the member, manager, trust or other entity - ---lf- - --------------- D Offic er ~ irector D Member D Manag er [name]
~-OtM'ltN/J D General Partner D Limited Partner
other ? ~(.St~ ~N ,--
~ Gn'--""~c....,,,c,...· LO~· /\..-,.-----=----r--------rvt----,U.,,,-fl __ 12B~i-· ~ Offic er Dir ector Member Manag er [name] /
BP-1~1'J WAL,.113'- []:"General Partner D Limited Partner D Other ____________ _
---=:...------==-----+---o1;;...e:: -f------c...-,::.- - ----'------- D Officer D Director D Member D Manager [name]
(V} Ur- M fy ff'-'tofF- · [tGeneral Partner D Limited Partner (Revised 09 13 18)
D Other _____________ _
CITY OF PALM SPRINGS - PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
Item 1X - Page 9
7, Owners/Investors with a 5% beneficial interest in the Annllcant Entltv or a related entltv
EXAMPLE
JANE DOE 50%, ABC COMPANY, Inc.
[name of owner/investor] [percentage of beneficial Interest In entity and name of entltvl
A.
[name of owner/investor] [percentage of beneficial interest in entity
and name of entitvl
B.
[name of owner/Investor] [percentage of beneficial Interest in entity
and name of entitvl
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 entitvl
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.
(Revised 09 13 18)
Date
CITY OF PALM SPRINGS - PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM