ATTACHMENT B
Public Integrity Disclosure
CITY OF PALM SPRINGS PUBLIC INTEGRITY DISCLOSURE APPLICANT DISCLOSURE FORM Page 1 of 2 (Revised 05/16/19) PUBLIC INTEGRITY DISCLOSURE APPLICANT DISCLOSURE FORM 1.Name of Entity2.Address of Entity (Principle Place of Business)3.Local or California Address (ifdifferent than #2)4.State where Entity is Registered with Secretary of StateIf other than California, is the Entity also registered in California? Yes No5.Type of EntityCorporation Limited Liability Company Partnership Trust Other (please specify)6.Officers, Directors, Members, Managers, Trustees, Other Fiduciaries(please specify)_________________________________________________ Officer Director Member Manager[name]General Partner Limited PartnerOther ____________________________________ _________________________________________________ Officer Director Member Manager[name] General Partner Limited Partner Other ____________________________________ _________________________________________________ Officer Director Member Manager[name] General Partner Limited Partner Other ____________________________________ CITY OF PALM SPRINGS PUBLIC INTEGRITY DISCLOSURE APPLICANT DISCLOSURE FORM Page 1 of 2 (Revised 05/16/19)
7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity EXAMPLE [name of owner/investor] [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 PENALTIES Falsification of information or failure to report information required to be reported may subject you to administrative action by the City.