ATTACHMENT "C"
REQUEST FOR PROPOSALS (RFP) #22-053
ON-CALL POTHOLE REPAIR AND
ASPHALT MAINTENANCE SERVICES
CONFLICT DISCLOSURE FORM
DISCLOSURES REQUIRED BY PERSONS OR ENTITIES
CONTRACTING WITH THE CITY OF RIAL TO•
Pursuant lo City of Rialto Municipal Code Section 2.48.510. all persons or business entities supplying any goods or services lo the city, or seeking a loan or grant awarded by the city. whether through an application or proposal, shall disclose in such application or proposal whether any city officer, employee, or consultant may have a financial or non-financial interest in the person or business entity, or in any member, employee. owner, or officer of the business entity. • A financial interest shall mean any interest that is prohibited under state law, including Galifomia Government Code Sections 1090 and 87100. and California Code of Regulation Section 18700 et seq.
• A non-financial interest shall mean any Interest lhat is prohibited by City of Rialto Municipal Code Section 2.48.450.
For the purpose of helping the City understand whether City personnel might have a conmct of Interest In you or your organization, please disclose below whether you or any of your members. employees. paid or unpaid omcers, paid or unpaid directors, or owners are (or are related to) a City elected or appointed official, a City officer, or a City employee or consultant.
Relatlonship Between the
Name of Your Organization's Name of City Elected or Two Affected Member, Employee, Appointed Official, City
Paid or Unpaid Officer, Paid or Officer, a City Employee or Unpaid Director, or Owner Consultant
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By submitting this [application/proposal), or supplying any goods or services to the Qty. the [applican1/vendor/oontractor/consultant] hereby attes under penalty of perjury, personally and/or on behalf of the entity [submitting this application/proposal or sup, lying any goods or services to the City] that no City of Rialto elected or appointed official, employee or consulta has a financial or non-financial interest, as such terms are defined in California Government Code Sedions 1 0 and 87100 and in City of Rialto Code of Ordinances Section
2.48.145, in the (applicantJvendor /contractor/co ullanl), except as specifically disciosed herein.
Name or PersorvEntity: _H_a_rd��&_H_a�......,..�----------- Form Date 1
Date: March 7, 2022
RFP #22-053
Attachment "C"
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