DISCLOSURE FORM
(Form 3 of 5)
P
roject Title: ____________________________________________________________ P
roject Address: _________________________________________________________ I
NTERESTED PARTIES:
P
lease provide the name of each individual, partnership, corpora�on, LLC, or trust who has an interest in the proposed land use ac�on. Include the names of all applicants, developers, property owners, and each person or en�ty that holds an op�on on the property.
I
ndividuals: Iden�fy all individuals
Partnerships: Iden�fy all general and limited partners
Corpora�ons: Iden�fy all shareholders owning 10% or more of the stock and all officers and directors (Unless the corpora�on is listed on any major stock exchange, in which case only the iden�ty of the exchange must be listed).
LLCs: Iden�fy all members, managers, partners, officers, and directors Trusts: Iden�fy all trustees and beneficiaries.
Op�on Holders: Iden�fy all holders of op�ons on the real property.
Fu
ll Name: Address
A
FFILIATED PARTIES:
I
n addi�on, please iden�fy the name of each civil engineer, architect, and consultant for the project
Fu
ll Name: Address:
Attachment 1
Addi�onal names and addresses atached:
☐ YES ☐ NO
The above informa�on shall be promptly updated by the applicant to reflect a change that occurs prior to final ac�on.
I cer�fy that the above informa�on is true and correct:
_________________________________ ________________________ Applicant Signature Date
LEVINE ACT DISCLOSURE STATEMENT
INSTRUCTIONS: All persons shall include this Disclosure Form along with their applica�on to the City. Failure to comply with this requirement may cause your applica�on to be rejected. In the space provided below, please iden�fy the applicable decision-making body with review authority over your applica�on. Iden�fy all the applicable officers and the amount of contribu�on given to each officer. Please see the City of Santa Rosa webpages for informa�on regarding the members of the various decision-making bodies (City Council, Planning Commission, Design Review Board, Cultural Heritage Board, etc.). Any ques�ons regarding the informa�on required to be disclosed in this form should be directed to the City Atorney.
California Government Code sec�on 84308, commonly referred to as the “Levine Act,” precludes an elected or appointed officer of a local government agency from making, par�cipa�ng in, or in any way atemp�ng to influence decisions by the agency if the officer receives any poli�cal contribu�ons totaling more than $250 in the 12 months preceding the decision, wh ile the decision is pending, and for 12 months following the final decision by the agency, when the contribu�on is from any person that has a financing interest in the decision. This prohibi�on applies to: (a) any license, permit, or other en�tlement for use considered by the local agency for any business, profession or trade, land use licenses and permits, and all other en�tlements for use considered by the local agency; and (b) contribu�ons made directly to the officer, received by the officer on behalf of any other officer , or received on behalf of any candidate for office or on behalf of any commitee. The Levine Act also requires disclosure of any such contribu�ons to be made by the applicant seeking the approval by the local agency.
LEVINE ACT DISCLOSURES:
1. Ha ve you or your compan y , or an y agent on behalf of you or your compan y , made an y contribu�ons of more than $250 to any elected or appointed officer of the City Council,
Planning Commission or other decision-making body in the 12 months preceding the date your applica�on was submited to the City?
☐ YES ☐ NO
If yes, please iden�fy the specific elected or appointed officer by name, and indicate the amount of any such campaign contribu�on(s):
Name of Officer:_____________________________________________________
Name of Decision-Making Body:_________________________________________
Amount of Contribu�on:_______________________________________________
2. Do you or your company , or any agent on behalf of you or your company, an�cipate or plan to make any contribu�ons of more than $250 to any elected or appointed officer of the City Council, Planning Commission, or other applicable decision-making body a�er the date of the City’s final decision on your applica� on, or in the 12 months a�er the City’ s decision on the applica�on?
☐YES ☐NO
If yes, please iden�fy the specific officer by name:
Name of Officer: ______________________________________________________
Name of Decision-Making Body:__________________________________________
NOTE: Answering yes to either of the two (2) ques�ons above does not preclude the City of Santa Rosa from approving your applica�on. It does, however, preclude the iden�fied officer(s) from making, par�cipa�ng in, or in any way atemp�ng to influence the decision.
Failing to provide full and accurate informa�on on this form may be grounds for denial of your applica�on, may render an approval null and void, and other legal penal�es.
DATE _______________________ ________________________________________
NAME OF COMPANY
________________________________________
NAME & TITLE
_________________________________________
SIGNATURE OF AUTHORIZED OFFICIAL