DISCLOSURE FORM
(Form 3 of 5)
Project Title: ____________________________________________________________ Project Address: _________________________________________________________ INTERESTED PARTIES:
Please provide the name of each ŝŶĚŝǀŝĚƵĂů͕ƉĂƌƚŶĞƌƐŚŝƉ͕ĐŽƌƉŽƌĂƟŽŶ͕>>͕ŽƌƚƌƵƐƚǁŚŽŚĂƐĂŶ ŝŶƚĞƌĞƐƚŝŶƚŚĞƉƌŽƉŽƐĞĚůĂŶĚƵƐĞĂĐƟŽŶ͘/ŶĐůƵĚĞƚŚĞŶĂŵĞƐŽĨĂůůĂƉƉůŝĐĂŶƚƐ͕ĚĞǀĞůŽƉĞƌƐ͕ƉƌŽƉĞƌƚLJ ŽǁŶĞƌƐ͕ĂŶĚĞĂĐŚƉĞƌƐŽŶŽƌĞŶƟƚLJƚŚĂƚŚŽůĚƐĂŶŽƉƟŽŶŽŶƚŚĞƉƌŽƉĞƌƚLJ͘ /ŶĚŝǀŝĚƵĂůƐ͗ /ĚĞŶƟĨLJĂůůŝŶĚŝǀŝĚƵĂůƐ
Partnerships: /ĚĞŶƟĨLJĂůůŐĞŶĞƌĂůĂŶĚůŝŵŝƚĞĚƉĂƌƚŶĞƌƐ
ŽƌƉŽƌĂƟŽŶƐ͗ / Ě Ğ Ŷ Ɵ Ĩ LJ Ă ů ů Ɛ Ś Ă ƌ Ğ Ś Ž ů Ě Ğ ƌ Ɛ Ž ǁ Ŷ ŝ Ŷ Ő ϭ Ϭ й Ž ƌ ŵ Ž ƌ Ğ Ž Ĩ ƚ Ś Ğ Ɛ ƚ Ž Đ Ŭ Ă Ŷ Ě Ă ůů ŽĸĐĞƌƐ ĂŶĚ ĚŝƌĞĐƚŽƌƐ;hŶůĞƐƐƚŚĞĐŽƌƉŽƌĂƟŽŶŝƐůŝƐƚĞĚŽŶĂŶLJŵĂũŽƌƐƚŽĐŬĞ džĐŚĂŶŐĞ͕ŝŶǁŚŝĐŚ case oŶůLJƚŚĞŝĚĞŶƟƚLJŽĨƚŚĞĞdžĐŚĂŶŐĞŵƵƐƚďĞůŝƐƚĞĚͿ͘
>>Ɛ͗ /ĚĞŶƟĨLJĂůůŵĞŵďĞƌƐ͕ŵĂŶĂŐĞƌƐ͕ƉĂƌƚŶĞƌƐ͕ŽĸĐĞƌƐ͕ĂŶĚĚŝƌĞĐƚŽƌƐ Trusts: /ĚĞŶƟĨLJĂůůƚƌƵƐƚĞĞƐĂŶĚďĞŶĞĮĐŝĂƌŝĞƐ͘
KƉƟŽŶ,ŽůĚĞƌƐ͗/ĚĞŶƟĨLJĂůůŚŽůĚĞƌƐŽĨŽƉƟŽŶƐŽŶƚŚĞƌĞĂůƉƌŽƉĞƌƚLJ͘ Full Name: Address
AFFILIA
TED PARTIES:
/Ŷ ĂĚĚŝƟŽŶ͕ ƉůĞĂƐĞ ŝĚĞŶƟĨLJ ƚŚĞ ŶĂŵĞ ŽĨ ĞĂĐŚ Đŝǀŝů ĞŶŐŝŶĞĞƌ͕ ĂƌĐŚŝƚĞĐƚ͕ ĂŶĚ ĐŽŶƐƵůƚĂŶƚ ĨŽƌ ƚŚĞ project
Full Name: Address:
Dutton Avenue Development Project
3150 Dutton Avenue, Santa Rosa, CA 95409
ESA 2600 Capitol Ave # 200, Sacramento, CA 95816
Padalin Funding, Inc. 430 Ridge Road, Tiburon, CA 94920 Attachment 1
ĚĚŝƟŽŶĂůŶĂŵĞƐĂŶĚĂĚĚƌĞƐƐĞƐĂƩĂĐŚĞĚ͗
տ YES տ NO
dŚĞĂďŽǀĞŝŶĨŽƌŵĂƟŽŶƐŚĂůůďĞƉƌŽŵƉƚůLJƵƉĚĂƚĞĚďLJƚŚĞĂƉƉůŝĐĂŶƚƚŽƌĞŇĞĐƚa ĐŚĂŶŐĞƚŚĂƚŽĐĐƵƌƐ ƉƌŝŽƌƚŽĮŶĂůĂĐƟŽŶ͘
/ĐĞƌƟĨLJƚŚĂƚƚŚĞĂďŽǀĞŝŶĨŽƌŵĂƟŽŶŝƐƚƌƵĞĂŶĚĐŽƌƌĞĐƚ͗
_________________________________ ________________________ ƉƉůŝĐĂŶƚ^ŝŐŶĂƚƵƌĞ D a t e
LEVINE ACT DISCLOSURE STATEMENT
INSTRUCTIONS: ůůƉĞƌƐŽŶƐƐŚĂůůŝŶĐůƵĚĞƚŚŝƐŝƐĐůŽƐƵƌĞ&ŽƌŵĂůŽŶŐǁŝƚŚƚŚĞŝƌĂƉƉůŝĐĂƟŽŶƚŽƚŚĞ ŝƚLJ͘&ĂŝůƵƌĞƚŽĐŽŵƉůLJǁŝƚŚƚŚŝƐƌĞƋƵŝƌĞŵĞŶƚŵĂLJĐĂƵƐĞLJŽƵƌĂƉ ƉůŝĐĂƟŽŶƚŽďĞƌĞũĞĐƚĞĚ͘/ŶƚŚĞ ƐƉĂĐĞƉƌŽǀŝĚĞĚďĞůŽǁ͕ƉůĞĂƐĞŝĚĞŶƟĨLJƚŚĞĂƉƉůŝĐĂďůĞĚĞĐŝƐŝŽŶ-ŵĂŬŝŶŐďŽĚLJ ǁŝƚŚƌĞǀŝĞǁĂƵƚŚŽƌŝƚLJ ŽǀĞƌLJŽƵƌĂƉƉůŝĐĂƟŽŶ͘/ĚĞŶƟĨLJall the aƉƉůŝĐĂďůĞŽĸĐĞƌƐĂŶĚƚŚĞĂŵŽƵŶƚŽĨĐŽŶƚƌŝďƵƟŽŶŐŝǀĞŶƚŽ ĞĂĐŚŽĸĐĞƌ ͘WůĞĂƐĞƐĞĞƚŚĞŝƚLJŽĨ^ĂŶƚĂZŽƐĂǁĞďƉĂŐĞƐĨŽƌŝŶĨŽƌŵĂƟŽŶƌĞŐĂƌĚŝŶŐƚŚĞŵĞŵďĞƌƐ of the various decision-ŵĂŬŝŶŐďŽĚŝĞƐ;ŝƚLJŽƵŶĐŝů͕WůĂŶŶŝŶŐŽŵŵŝƐƐŝŽŶ͕ĞƐŝŐŶZĞǀŝĞǁŽĂƌĚ͕ ƵůƚƵƌĂů,ĞƌŝƚĂŐĞŽĂƌĚ͕ĞƚĐ͘Ϳ͘ŶLJƋƵĞƐƟŽŶƐƌĞŐĂƌĚŝŶŐƚŚĞŝŶĨŽƌŵĂƟŽŶƌĞƋƵŝƌĞĚƚŽďĞĚŝƐĐůŽƐĞĚ ŝŶƚŚŝƐĨŽƌŵƐŚŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽƚŚĞŝƚLJƩŽƌŶĞLJ͘
ĂůŝĨŽƌŶŝĂ'ŽǀĞƌŶŵĞŶƚŽĚĞƐĞĐƟŽŶϴϰϯϬϴ͕ĐŽŵŵŽŶůLJƌĞĨĞƌƌĞĚƚŽĂƐƚŚĞ͞>ĞǀŝŶĞĐƚ͕͟ƉƌĞĐůƵĚĞƐ an elected or appŽŝŶƚĞĚŽĸĐĞƌŽĨĂůŽĐĂůŐŽǀĞƌŶŵĞŶƚĂŐĞŶĐLJĨƌŽŵŵĂŬŝŶŐ͕ƉĂƌƟĐŝƉĂƟŶŐŝŶ͕ŽƌŝŶ ĂŶLJ ǁĂLJ ĂƩĞŵƉƟŶŐ ƚŽ ŝŶŇƵĞŶĐĞ ĚĞĐŝƐŝŽŶƐ ďLJ ƚŚĞ ĂŐĞŶĐLJ ŝĨ ƚŚĞ ŽĸĐĞƌ ƌĞĐĞŝǀĞƐ ĂŶLJ ƉŽůŝƟĐĂů ĐŽŶƚƌŝďƵƟŽŶƐ ƚŽƚĂůŝŶŐ ŵŽƌĞ ƚŚĂŶ ΨϮϱϬ ŝŶ ƚŚĞ ϭϮ ŵŽŶƚŚƐ ƉƌĞĐĞĚŝŶŐƚ Ś Ğ Ě Ğ Đ ŝ Ɛ ŝ Ž Ŷ ͕ ǁ Śile the ĚĞĐŝƐŝŽŶ ŝƐ ƉĞŶĚŝŶŐ͕ ĂŶĚ ĨŽƌ ϭϮ ŵŽŶƚŚƐ ĨŽůůŽǁŝŶŐ ƚŚĞ ĮŶĂů ĚĞĐŝƐŝŽŶ ďLJ ƚŚĞ ĂŐĞŶĐLJ͕ ǁŚĞŶ ƚŚĞ Đ Ž Ŷ ƚ ƌ ŝ ď Ƶ Ɵ Ž Ŷ ŝ Ɛ Ĩ ƌ Ž ŵ Ă Ŷ LJ Ɖ Ğ ƌ Ɛ Ž Ŷ ƚ Ś Ă ƚ Ś Ă Ɛ Ă Į Ŷ Ă Ŷ Đ ŝ Ŷ Ő ŝ Ŷ ƚ Ğ ƌ Ğ Ɛ ƚ ŝ Ŷ ƚŚĞ ĚĞĐŝƐŝŽŶ͘ dŚŝƐ ƉƌŽŚŝďŝƟŽŶ ĂƉƉůŝĞƐƚŽ͗;ĂͿĂŶLJůŝĐĞŶƐĞ͕ƉĞƌŵŝƚ͕ŽƌŽƚŚĞƌĞŶƟƚůĞŵĞŶƚĨŽƌƵƐĞĐŽŶƐŝĚĞƌĞĚďLJƚŚĞůŽĐĂůĂŐĞŶĐLJĨŽƌ ĂŶLJďƵƐŝŶĞƐƐ͕ƉƌŽĨĞƐƐŝŽŶŽƌƚƌĂĚĞ͕ůĂŶĚƵƐĞůŝĐĞŶƐĞƐĂŶĚƉĞƌŵŝƚ Ɛ͕ĂŶĚĂůůŽƚŚĞƌĞŶƟƚůĞŵĞŶƚƐĨŽƌ ƵƐĞĐŽŶƐŝĚĞƌĞĚďLJƚŚĞůŽĐĂůĂŐĞŶĐLJ͖ĂŶĚ;ďͿĐŽŶƚƌŝďƵƟŽŶƐŵĂĚĞĚŝƌĞĐƚůLJƚŽƚŚĞŽĸĐĞƌ͕ƌĞĐĞŝǀĞĚďLJ ƚŚĞŽĸĐĞƌŽŶďĞŚĂůĨŽĨĂŶLJŽƚŚĞƌŽĸĐĞƌ͕ŽƌƌĞĐĞŝǀĞĚŽŶďĞŚĂůĨŽ ĨĂŶLJĐĂŶĚŝĚĂƚĞĨŽƌŽĸĐĞŽƌŽŶ ďĞŚĂůĨŽĨĂŶLJĐŽŵŵŝƩĞĞ͘dŚĞ>ĞǀŝŶĞĐƚĂůƐŽƌĞƋƵŝƌĞƐĚŝƐĐůŽƐƵƌĞŽĨĂŶLJƐƵĐŚĐŽŶƚƌŝďƵƟŽŶƐƚŽďĞ ŵĂĚĞďLJƚŚĞĂƉƉůŝĐĂŶƚƐĞĞŬŝŶŐƚŚĞĂƉƉƌŽǀĂůďLJƚŚĞůŽĐĂůĂŐĞŶĐLJ͘
LEVINE ACT DISCLOSURES:
ϭ͘ , Ă ǀ ĞLJ ŽƵ Žƌ LJ ŽƵ ƌĐ Žŵ ƉĂ Ŷ LJ ͕Žƌ Ă Ŷ LJ ĂŐ Ğ Ŷ ƚ Ž ŶďĞ Ś ĂůĨŽĨ LJ Ž ƵŽƌ LJ ŽƵƌĐ ŽŵƉ ĂŶ LJ ͕ŵĂ ĚĞ ĂŶ LJ ĐŽŶƚƌŝďƵƟŽŶƐŽĨŵŽƌĞƚŚĂŶΨϮϱϬƚŽĂŶLJĞůĞĐƚĞĚŽƌĂƉƉŽŝŶƚĞĚŽĸĐĞ ƌof the ŝƚLJŽƵŶĐŝů͕
WůĂŶŶŝŶŐŽŵŵŝƐƐŝŽŶŽƌŽƚŚĞƌdecision-ŵĂŬŝŶŐďŽĚLJ ŝŶƚŚĞϭϮŵŽŶƚŚƐƉƌĞĐĞĚŝŶŐƚŚĞĚĂƚĞ LJŽƵƌĂƉƉůŝĐĂƟŽŶǁĂƐƐƵďŵŝƩĞĚƚŽƚŚĞŝƚLJ͍
տ YES տ NO
/ĨLJĞƐ͕ƉůĞĂƐĞŝĚĞŶƟĨLJƚŚĞƐƉĞĐŝĮĐĞůĞĐƚĞĚŽƌĂƉƉŽŝŶƚĞĚŽĸĐĞƌď LJŶĂŵĞ͕ĂŶĚŝŶĚŝĐĂƚĞƚŚĞ ĂŵŽƵŶƚŽĨĂŶLJƐƵĐŚĐĂŵƉĂŝŐŶĐŽŶƚƌŝďƵƟŽŶ;ƐͿ͗
EĂŵĞŽĨKĸĐĞƌ͗_____________________________________________________
Name of Decision-DĂŬŝŶŐŽĚLJ:_________________________________________
ŵŽƵŶƚŽĨŽŶƚƌŝďƵƟŽŶ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Ϯ͘ ŽLJŽƵŽƌLJŽƵƌĐŽŵƉĂŶLJ ͕ŽƌĂŶLJĂŐĞŶƚŽŶďĞŚĂůĨŽĨLJŽƵŽƌLJŽƵƌĐ ŽŵƉĂŶLJ͕ĂŶƟĐŝƉĂƚĞŽƌ ƉůĂŶƚŽŵĂŬĞĂŶLJĐŽŶƚƌŝďƵƟŽŶƐŽĨŵŽƌĞƚŚĂŶΨϮϱϬƚŽĂŶLJĞůĞĐƚĞĚ ŽƌĂƉƉŽŝŶƚĞĚŽĸĐĞƌŽĨ ƚŚĞŝƚLJŽƵŶĐŝů͕WůĂŶŶŝŶŐŽŵŵŝƐƐŝŽŶ͕ŽƌŽƚŚĞƌĂƉƉůŝĐĂďůĞdecision-ŵĂŬŝŶŐďŽĚLJ ĂŌĞƌƚŚĞ ĚĂƚĞŽĨƚŚĞŝƚLJ͛ ƐĮŶĂůĚĞĐŝƐŝŽŶŽŶLJŽƵƌĂƉƉůŝĐĂƟŽŶ͕ŽƌŝŶƚŚĞ ϭϮŵŽŶƚŚƐĂŌĞƌƚŚĞŝƚLJ͛ Ɛ ĚĞĐŝƐŝŽŶŽŶƚŚĞĂƉƉůŝĐĂƟŽŶ͍
տYES տNO
/ĨLJĞƐ͕ƉůĞĂƐĞŝĚĞŶƟĨLJƚŚĞƐƉĞĐŝĮĐŽĸĐĞƌďLJŶĂŵĞ͗
EĂŵĞŽĨKĸĐĞƌ͗ͺͺͺ___________________________________________________
Name of Decision-DĂŬŝŶŐŽĚLJ:__________________________________________
NOTE͗ŶƐǁĞƌŝŶŐLJĞƐƚŽĞŝƚŚĞƌŽĨƚŚĞƚǁŽ;ϮͿƋƵĞƐƟŽŶƐĂďŽǀĞĚŽĞƐŶŽƚƉƌĞĐůƵĚĞƚŚĞŝƚLJ ŽĨ^ĂŶƚĂZŽƐĂĨƌŽŵĂƉƉƌŽǀŝŶŐLJŽƵƌĂƉƉůŝĐĂƟŽŶ͘/ƚĚŽĞƐ͕ŚŽǁĞǀĞƌ͕ƉƌĞĐůƵĚĞƚŚĞŝĚĞŶƟĮĞĚ ŽĸĐĞƌ;ƐͿĨƌŽŵŵĂŬŝŶŐ͕ƉĂƌƟĐŝƉĂƟŶŐŝŶ͕ŽƌŝŶĂŶLJǁĂLJĂƩĞŵƉƟŶŐƚŽŝŶŇƵĞŶĐĞƚŚĞĚĞĐŝƐŝŽŶ͘ &ĂŝůŝŶŐƚŽƉƌŽǀŝĚĞĨƵůůĂŶĚĂĐĐƵƌĂƚĞŝŶĨŽƌŵĂƟŽŶŽŶƚŚŝƐĨŽƌŵŵĂLJďĞŐƌŽƵŶĚƐĨŽƌĚĞŶŝĂůŽĨ LJŽƵƌĂƉƉůŝĐĂƟŽŶ͕ŵĂLJƌĞŶĚĞƌĂŶĂƉƉƌŽǀĂůŶƵůůĂŶĚǀŽŝĚ͕ĂŶĚŽƚŚĞƌůĞŐĂůƉĞŶĂůƟĞƐ͘
DATE _______________________ ________________________________________ ED
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Paladin Funding, Inc.
Mark M. Garay, President