Attachment A
Public Integrity Disclosure Forms
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
Corporation Limited Liability Company Partnership Trust Other (please specify)
6. Officers, Directors, Members, Mana gers, Trustees, Other Fiduciaries (please s pecify) Note: If any response is not a natural pers on, 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 ____________________________________
_________________________
________________________ Officer Director Member Manager [name]
General Partner Limited Partner
Other ____________________________________
_________________________
________________________ Officer Director Member Manager [name]
General Partner Limited Partner
Other ____________________________________
Veolia Water West Operating Services, Inc.
53 State Street, 14th Floor, Boston, MA 02109
Delaware
x
x
William DiCroce x x
Jason Salgo x x
Robert Arendell x x
CITY OF PALM SPRINGS – PUBLIC INTEGRITY DISCLOSURE FORM 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.
Signature of Disclosing Party, Printed Name, Title Date Veolia Water North America-West, LLC 100%
Continuation Page
Item 6, continued
John Gibson, officer
James Pawloski, officer
Daniel Mahoney, officer
Keith Oldewurtel, officer
Francis Ferrara, officer
Each of the persons listed in Item 6 (except James Pawloski) also serve as the officers of Applicant’s parent company Veolia Water North America-West, LLC, and William DiCroce, Jason Salgo, and Robert Arendell also serve as managers of Veolia Water North America-West, LLC.