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REQUEST FOR QUALIFICATIONS (RFQ) #25-019
ON-CALL ASPHALT AND CONCRETE MAINTENANCE
SERVICES
CONFLICT DISCLOSURE FORM
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CITY OF RIALTO
DISCLOSURES REQUIRED BY PERSONS OR ENTITIES
CONTRACTING WITH THE CITY OF RIALTO*
Pursuant to City of Rialto Munidpal Code Section 2.48.510, all persons or business entities supplying any goods or services to lhe dty, or seeklng a loan or grant awarded by the city, whether through an appllcaUon or proposal, sh all disclose in such appllcaUon or proposal whether any city officer, employee, or consultant may have a financial or non-financial interest In lhe person or buslness entity, or in any member, employee, owner, or officer of lhe business entity. • A financial Interest shall mean any Interest that is prohibited under state law, including Califomia Government Code Sections 1090 and 87100, and Califomla Code of Regulation Sectbn 18700 et seq.
• A non-financial lnterest shaU mean any Interest that is prohibited by City of Rialto Municipal Code SecUon 2.48.450.
For the purpose of helping the City understand whether City personnel might have a confllct of Interest In you or your organlzaUon, please disclose below whether you or any of your members, employees. paid or unpaid officers, paid or unpaid directors, or owners are (or are related to) a City elected or appolnted official, a City officer, or a City employee or consultant Relationship e.tw.en th•
Name of Your Organization's Name of City Electad or Two Affected Member, EmployN, Appanted Offldal, City
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Paid or Unpaid Officer, Paid or Offlcer, a City EmployN or Unoald Director or Owner Consultant
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By submitting this (application/proposaij, or supplying any goods or services to the Oty, the [applicant/vendor/contractor/oonsultwllj hereby attests urider penalty of perjury, personaUy and/or on behalf of the entity (submitting this application/proposal or supplying any goods or services to the City] that no City of Rialto elected or appo.inted official, employee or consultant has a financial or n�financial interest, as such tenns are defined in Cslifomia Government Code Sections 1090 and 87100 and in City of RJalto Code of Ordinances Section
2.48.145, in the (applicantlvendor/contractor/oonsuttant), except as specifically disclosed herein.
Name of Person/Entity: Michael Amundson
Tnle: Vice��
Signature: -�---::2
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Form Date 11/1112021
Date: Februacy ) 8, 2025
RFQ #25-019
Attachment "C"
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