ATTACHMENT C
OF CITY OF PASADENA
APPLICATION FOR APPOINTMENT TO THE
PASADENA RENTAL HOUSING BOARD
FORM RHB-001
The information contained on this form will be used by the City Council to fill vacancies on the Pasadena Rental Housing Board. Please answer all questions. You are invited to attach additional pages, a copy of your resume, or submit supplemental information which you feel may assist the City Council in its evaluation of your application. Applications will be purged from the City's files January 31 of each year. If you have not been appointed to the Rental Housing Board and still desire to be considered for appointment, please resubmit an updated application, or advise City staff in writing that the initial form is still current and can be used for an additional year.
Applicant Name:
Home Address:
Mailing Address:
Email Address:
Business Phone: Date Available to Start:
Home Phone: Cell Phone:
Board Seat Type: Indicate the type of Board seat in which you wish to fill (mark one or more):
Tenant Member (7 seats, one per Council district, reserved for tenants) Representing City Council District
At-large Member (4 seats, open to any Pasadena resident without respect to tenancy)
Alternate Tenant Member (1 seat, reserved for tenants)
Alternate At-large Member (1 seat, open to any Pasadena resident without respect to tenancy)
Community Service - List boards, commissions, committees, and organizations on which you are currently serving or have served, offices held and in what city.
Employment - Title and duties, current and past (acceptable to attach resume as an alternative).
Education - Include professional or vocational licenses or certificates.
1. Have you ever worked for the City of Pasadena? (If yes, please YES NO list dates/department)
2. Are you related to any employee, appointed or elected official of YES NO the City of Pasadena? (If yes, please indicate name and relationship)
3. Are you aware that financial disclosure is required annually? YES NO (e.g., sources of income, loans and gifts, investments, interests in real property)
4. Rules of law and ethics prohibit members from participating in YES NO and voting on matters in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest which may develop from your occupation, or economic holdings, in relation to your responsibilities as a member of the Rental Housing Board? (If yes, please indicate any potential conflicts)
5. Do you, or your extended family' members, have a material YES NO interest in rental property in the County of Los Angeles within the last three years?
6. Do you reside at a property owned or managed by a member of YES NO the City Council, or any member of the City Council's extended family, or in which any member of the City Council, or member of the City Council's extended family, has any ownership stake in said property?
7. Have there been, or are there now, any personal or business YES NO circumstances which might reflect adversely on the propriety of your serving as a member of the Pasadena Rental Housing Board?
8. Are you aware of the time commitment necessary to fulfill the YES NO obligations of the Pasadena Rental Housing Board?
Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Charter Section 1803(g)).
YES NO
9. Are you aware that you may serve no more than eight
consecutive years as a member of the Pasadena Renta
Housing Board?
10. Describe your relevant life experience, professional training, and or education in the following areas: Housing/Housing Justice/Landlord Tenant Relationships/Real Estate:
11. How would you add value to the Pasadena Rental Housing Board?
12. What do you view are the primary objectives and goals of the Pasadena Rental Housing Board?
13. How would you help to achieve these objectives and goals? (printed name), declare under penalty of perjury under the law o the State of California that the information reported in this Form RHB-001 is true, accurate, and complete.
Signed this day of _, 20_
Signed:
Printed Name:
CITY OF PASADENA
Residency Verification - MANDATORY
All applicants must provide proof of residency in a City Council district under section 1811(b) of The Pasadena Fair and Equitable Housing Charter Amendment (Measure H). Proof of residency may be established by either of the following:
1. If you are a registered voter, please complete and sign the following declaration and the City Clerk will verify your signature on file with the Los Angeles County Registrar of Voters.
I am a resident of District No. _ of the City of Pasadena I reside at (street), Pasadena,
CA (zip code).
Signed:
Printed Name:
2. If you are not a registered voter, please provide clear, readable two forms of proof of residency acceptable to the Department of Motor Vehicles (DMV) for a REAL ID, listed below (Cal. Code Regs. tit. 13, § 17.00 and § 15.01(d)).
Please provide clear, readable copies of two (2) documents from the following list and attach to this application:
: Home utility bill or cellular phone bill
Records from any state or national bank, state or federal savings association, trust company, industrial loan company, state or federal credit union, or any institution or entity that has issued a credit card
• Insurance documents, including medical, dental, vision, life, home, rental or vehicle
• Medical documents
• A document issued by a U.S. government agency, meaning an entity, office, or authority governing over a country, state, county, city, municipality, district, agency, department, or any other political subdivision of a country or state • Mortgage bill
• Employment documents
• Tax return (either Internal Revenue Service (IRS) or California Franchise Tax Board (FTB)
• Rental or lease agreement with the signature of the owner/landlord and the tenant/resident
• School documents issued by a public or private primary, secondary, or post- secondary institution, college, or university that includes the applicant's date of birth. If using a foreign school document, it must be sealed by the school and include a photograph of the applicant at the age the record was issued.
Change of Address Confirmation by the U.S. Postal Service • Property tax bill or statement
• Letter attesting that the applicant resides in Pasadena from a homeless shelter, shelter for abused women, non-profit entity, faith-based organization, employer or government agency within the United States
• Deed or title to residential real property
• Voter registration confirmation letter or postcard issued by the California Secretary of State or the Los Angeles County Registrar of Voters • Proof of payment of resident tuition at a public institution of higher education in California
• An original copy of an approved Claim for Homeowners' Property Tax Exemption (BOE-266) form filed with the Los Angeles County Assessor • Court documents that list the applicant as a resident of Pasadena • California Certificate of Vehicle or Vessel Titles or registration (i.e., a title to, or a DMV registration for, a boat, truck or car)
• A DMV No Fee Identification Card Eligibility Verification (DL 933) form, completed and signed
• If your name does not appear on any residency documents, you may present a birth certificate, marriage license, or domestic partner registration certificate to trace your relationship to the person whose name does appear on the residency documentation.
• If the residency document reflects a name that differs from the tracing document due to a name change (for example, marriage, divorce, or court order), name change documentation is required.
OF PASADENA CITY OF PASADENA
CITY Supplement to Statement of Economic
Interest (FPPC Form 700)
(Form RHB-002)
All applicants must complete a Statement of Economic Interest (FPPC Form 700) and "Economic Interests Affidavit" attesting to the information reported in applicant's Form 700.
Instructions: The Pasadena Fair and Equitable Housing Charter Amendment (Measure H) prohibits Tenant Board and Alternate Tenant Board members from having "Material Interests in Rental Property" (defined below) at the time of their appointment and during their service. All applicants for all Board seats (both Tenant and At-Large) must report their own and their Extended Family's interests and dealings in rental properties in Los Angeles County in the three (3) years before submitting an application. The City is adopting the Fair Political Practices Commission's Form 700 for this purpose, but Measure H requires information about interests in rental property in Los Angeles County or three years, not the one year the FPPC Form otherwise uses. Under City Charter Section 1811(b), these documents are public records; they will not be confidential.
Measure H's Definitions:
Extended Family: any spouse, whether by marriage or not, domestic partner, parent, child, sibling, grandparent, aunt or uncle, niece or nephew, grandchild, or cousin (Section 1803(g)).
Material Interest in Rental Property: an individual has a Material Interest in Rental Property if they, or any member of their Extended Family, own, manage, or have a 5% or greater ownership stake in Rental Units in the county of Los Angeles, or if they or any member of their Extended Family owned, managed, or had a 5% or greater ownership stake in Rental Units in the county of Los Angeles in the past three (3) years (Section 1803(i)).
Rental Unit: any building, structure, or part thereof, or land appurtenant thereto, or any other rental property rented or offered for rent for residential purposes, whether or not such units possess a valid Certificate of Occupancy for use as rental housing, together with all housing services connected with use or occupancy of such property, such as common areas and recreational facilities held out for use by the Tenant (Section 1803(x)).
Tenant: a tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental housing agreement to the use or occupancy of any Rental Unit (Section 1803(aa)).
CITY OF PASADENA
Economic Interests Affidavit - MANDATORY
_ (printed name), declare under penalty of perjury under the law of the State of California that the information provided and reported on this reported in this Form RHB-002 and the attached Form 700 is true, accurate, and complete.
Signed this day of _, 20
Signed:
Printed Name: _
CITY OF PASADENA
Affidavit of Tenancy - MANDATORY for Tenant Board
JUNE and Tenant Alternate Seats
(Form RHB-003)
(printed name), declare under penalty of perjury under the law of the State of California that the foregoing is true and correct:
1. I am a tenant, subtenant, lessee, sublessee or any other person entitled under the terms of a rental agreement or lease (oral, written, or implied) for the use or occupancy of a rental unit. 2 fat oner a a pedin a rental ha sing agemen or late or by are provided prodiot a
3. I reside at the following address: (street),
Pasadena, California . (zip code)
Signed this day of _ 20_
Signed:
Printed Name: _
NOMINATION
OFFICIAL FILING FORM
PAPER
FOR THE PASADENA RENTAL HOUSING BOARD
City Clerk or Deputy City Clerk
Any person signing this Nomination Paper
MUST be a Resident of the SAME Date
District as the Nominee.
MUST OBTAIN AT LEAST 25 VALID SIGNATURES
We, the undersigned residents, hereby nominate
for appointment to the office of ............. ..PASADENA RENTAL HOUSING BOARD as alan: • Tenant Member representing District CAt-Large Member •Tenant Alternate Member CAt-Large Alternate Member Sign Name Residence Address For Official Use
1 Print Name
Sign Name Residence Address For Official Use
2 Print Name
Sign Name Residence Address For Official Use
3 Print Name
Sign Name Residence Address For Official Use
4 Print Name
Sign Name Residence Address For Official Use
5 Print Nam
Sign Name Residence Address For Official Use
6 Print Name
Sign Name Residence Address For Official Use
7 Print Name
Sign Name Residence Address For Official Use
8 Print Name
Sign Name Residence Address For Official Use
9 rint Nam
Sign Name Residence Address For Official Use
10 Print Name
Sign Name Residence Address For Official Use
11 Print Name
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Residence Address
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DECLARATION OF CIRCULATOR
ny person that is 18 years of age or older may circulate a nomination paper. (Only 1 circulator may circulate this nomination paper Do NOT type this section. It MUST be filled out in your own handwriting) _. solemnly swear (or affirm) all of the following:
(print name)
1. That I am 18 years of age or older.
2. That my residence address, including street and number, is . -. (if no street or number exists), a designation of my residence adequate to readily ascertain its location is
3. That the signatures on this nomination paper were obtained between the dates of and tai, the bes or my normation and bela, as signature is the genuine signature of the person iose name i purports to be.
I certify (or declare) under the penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed by me at - on -
(place) (date)
(Signature of Circulator)
AFFIDAVIT OF NOMINEE
AND OATH OR AFFIRMATION OF ALLEGIANCE
State of California
County of Los Angeles SS.
(Print Name of Nominee)
being duly sworn, says that he or she is
the above named nominee for appointment for : Pasadena Rental Housing Board Member and that his or her residence address is:
(Print residence address as provided by affiant)
do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and the Constitution of the State of California against emies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of Califor that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I certily (or detaire) under the penalty of perjury under the laws of the State of California that the foregoing is true and corect.
Executed by me at - on
(place) (mm,dd) (year)
(Signature of Candidate)
APPLICANT'S INFORMATION
Applicant's Name Day Phone
Applicant's Residence Address Evening Phone
Mailing Address (if different than above) Fax
City State Zip Email Address
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