DocuSign Envelope ID: 675DEE7D-1EE2-459F-BB73-AE466BCCD4C3 ATTACHMENT "C"
REQUEST FOR INFORMAL QUOTE (RFQ) #22-067
CEQA Consultant for Lake Rialto Habitat Management and Community Open Space Project
CONFLICT DISCLOSURE FORM
CITY OF RIALTO
DISCLOSURES REQUIRED BY PERSONS OR ENTITIES
CONTRACTING WITH THE CITY OF RIALTO*
Pursuant to City of Rialto Municipal Code Section 2.48.510, all persons or business entities supplying any goods or services to 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 California Government Code Sections 1090 and 87100, and California Code of Regulation Section 18700 et seq.
• A non-financial interest shall mean any interest that 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 conflict of interest in you or your organization, 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 appointed official, a City officer, or a City employee or consultant.
Relationship 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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submitting this [application/proposal], or supplying any goods or services to the City, Name of Person/Entity: Raymond V. Hussey
President
Title:
Signature karl V. Hussy Date: April 22, 2022
Form Date 11/11/2021
RFQ #22-067
Attachment "C"