ATTACHMENT “E”
Public Integrity 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? F Yes F No
5. Type of Entity
F Corporation F Limited Liability Company F Partnership F Trust F 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
________________________ F Officer F Director F Member F Manager [name] F General Partner F Limited Partner
FOther ___________________________
_______________________________ F Officer F Director F Member F Manager [name] F General Partner F Limited Partner
F Other __________________________
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________________________________ F Officer F Director F Member F Manager [name] F General Partner F Limited Partner
F 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 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 _______________________
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________________________________ ___________________________________________________________________________________ ______________ ______________ ___________________ ____