ATTACHMENT #3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
2. Do you or your organization, or any agency or representative on behalf of you or your organization, anticipate or plan to make any campaign contributions of more than $250 (aggregated) to any City Council member in the 12 months following any City Council action related to this proposal/application? .. There may be legal restrictions on making contributions during the 12 months following City Council Action. It is recommended that you consult with your own legal counsel regarding the requirements of law.
0 YES
[] NO
Council Member Name Payee Na!lle_ Payment Date )'�yment Amount ' - - -· -,-�- ----
Answering "YES" to either question above does not preclude the City of Thousand Oaks from entering into or taking any subsequent action related to this proposal/application. However, it may preclude the identified Council member(s) from participating in any actions/decisions related to this proposal/application.
11/3/2024
Date
Lisa Evans Powell
Printed Name/Tille of Authorized
Representative
s� 1gnature
CVUSD
Name of Business/Legal
Entity
""* You must submit a supplemental form if you make any new reportable contribution(s) while the proposal/application is being considered ,_
.. "Aggregated" contributions, as described in FPPC Regulation §18438.5, include the following types of contributions made during a 12-month period: (1) all contributions made by the party or participant; (2) all contributions made by an agent of the party or participant; and (3) all contributions made by an individual or entity required to be aggregated with the party or participant, and any agent of the party or participant. 2 CAO:650-90/tmn/Legal f-iles\Levine Act - Applications CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 C
C
S
:
4 8
3 -
1 0
\
H
:
\
C
O
M
M
O
N
\
C
o
m
m
u
n
i
t
y
S
e
r
v
i
c
e
s
\
C
i
t
y
C
o
u
n
c
i
l
\
C
o
u
n
c
i
l
I
t
e
m
s
\
2 0
2 4
S
t
a
f
f
R
e
p
o
r
t
s
\
1 2
0 3
2 0
2 4
\
C
o
m
m
u
n
i
t
y
S
p
o
r
t
s
G
r
a
n
t
C
F
R
C
R
e
c
o
m
m
e
n
d
a
t
i
o
n
s
\
L
e
v
i
n
e
A
c
t
D
i
s
c
l
o
s
u
r
e
F
o
r
m
A
t
t
a
c
h
m
e
n
t
3
481-15/\\ch-fs1-p\data\COMMON\Community Grants\2024-25 Grants\Sports\Applicants\NPHS Track & Field- need sigs\1Community Grants Application
9.3.2024.final.docx
E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
Cal
ifornia Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the party to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Counc
il members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levi
ne Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreement and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Lev ine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Hav
e you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☒ NO
CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2 Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15//Users/adelgadillo/Downloads/1Community Grants Application 9.3.2024.final.docx E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
California Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the p arty to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreem ent and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Levine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☐ NO
CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2 Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations \Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CF RC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Atta chment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CF RC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
CaliforniaGovernment Code section 84308 (Levine Act) prohibitsany Thousand Oaks City Council member from participatingin any actionrelatedto a contract,agreement,orfranchise agreement (excludinglaboror competitivelybid contracts)ifthe Councilmember receivesa campaign contributiontotalingmore than $250 (aggregated)from the partyto the contract, agreement or franchiseagreement, theiragents,or any financiallyinterestedparticipantwho activelysupportsoropposes the matterwithinthe previous twelve(12)months.Councilmembers must also discloseany eligiblecampaign contributionreceived onthe recordofthe proceeding.
Council members are prohibitedfrom accepting,soliciting,ordirectinga campaign contributionof more than $250 (aggregated)from a party,theiragent/representative,ora financiallyinterested participantduringa proceedingand for12 months followingthedate afinaldecisionismade. In addition,a party,theiragent/representative,ora financiallyinterestedparticipantisprohibitedfrom contributingmore than $250 (aggregated)to a Councilmember duringa proceedingandfor12 months followingthedate a finaldecisionismade.
The Levine Actalsorequirespartiestocertaincontracts,agreements,orfranchiseagreementsto discloseany campaign contributionover $250 (aggregated)withintheprecedingtwelve(12) months by the partytothe agreement,contract,orfranchiseagreementandtheiragents.The Levine Actdoes notapplytocompetitivelybid,labor,orpersonalemploymentcontracts. □ The LevineAct(GovCode § 84308)DOES NOT applyto thisproposal/application M The Levine Act(Gov Code § 84308)DOES applyto thisproposal/applicationandthe requireddisclosureissetforthbelow;
Haveyouoryourcompany,oranyagentonbehalfofyouoryourcompany,made campaigncontributionstotalingmorethan$250(aggregated)toanycouncilmember in the 12 months precedingthe date you submittedyour proposal/application,thedateyoucompletedthisform,ortheanticipateddateof Councilactionrelatedto thisproposal/application?
□ YES
1. any
[El NO
Payment AmountPayment DatePayee NameCouncil Member Name CAO;650-90/tmn/LegalFiles\LevineAct- Applications;Page2 of2
481-15/C:\Users\ufrod\Desktop\lCommunityGrantsApplication9.3.2024,final.docxCCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
Do you or your organization,or any agency or representativeon behalfofyou or your organization,anticipate orplantomake any campaign contributionsofmore than $250 (aggregated)to any CityCouncil member inthe 12 months following any CityCouncilactionrelatedto thisproposal/application? legalrestrictionson making contributionsduring the 12 months following CityCouncil Action. Itisrecommended thatyou consultwithyour own legal counsel regarding the requirements of law.
□ YES
2. There may be
lEI NO
Payment AmountPayment DatePayee NameCouncil Member Name Answering"YES” to eitherquestionabove does notprecludetheCityofThousand Oaksfrom enteringintoortakingany subsequentactionrelatedto thisproposal/application.However,itmay precludetheidentifiedCouncilmember(s)fromparticipatinginanyactions/decisionsrelatedto thisproposal/application.
TONS Track & Field BoosterSusan Walter,Directorof Fundraising9/18/24 Club
Name of Business/ Legal
Entity
Printed Name/ Titleof Authorized
Representative
Date
Signature*
*SignaturePolicy:The Citywillacceptactualwet signature,scannedcopyofactualwetsignature,oraverified digitalsignaturefromDocuSignorAdobe.ElectronicsignaturesthatareNOTdigitallyverifiedthroughDocuSign Adobe willnotbe accepted.The applicationmust be signedtobedeemed complete.or reportablecontribution(s)while theYou must submit a supplemental form ifyou make any proposal/applicationisbeingconsidered
new***
***
Aggregated”contributions,asdescribedinFPPC Regulation§18438.5,includethefollowing typesofcontributionsmade duringa 12-monthperiod;(1)allcontributionsmadebythepartyor participant:(2)allcontributionsmade by an agentofthepartyorparticipant;and(3)all contributionsmade by an individualor entityrequiredtobe aggregatedwiththepartyor participant,and anyagentofthepartyorparticipant.
**
CAO:650-90/tmn/LegalFiles\LevineAct- Applications;Page 1 of2
481-15/C:\Users\ufrod\Desktop\lCommunitYGrantsApplication9.3.2024.final.docx CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15//Users/soohyung.lee/Downloads/1Community Grants Application 9.3.2024.final (1).docx E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
California Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the p arty to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreem ent and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Levine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☒ NO
CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2 Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFR C Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024 \Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3 CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 St aff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
California Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the p arty to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreem ent and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Levine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☒ NO
CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2 Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations \Levine Act Disclosure Form Attachment 3
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15/\\ch-fs1-p\data\COMMON\Community Grants\2024-25 Grants\Sports\Applicants\Rancho Potrero\City of TO - SFEF Application - RPTR LLC.docx
LEVINE ACT DISCLOSURE FORM
Cal
ifornia Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the party to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Counc
il members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levi
ne Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreement and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Lev ine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Hav
e you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☒ NO
Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15/\\ch-fs1-p\data\COMMON\Community Grants\2024-25 Grants\Sports\Applicants\Rancho Potrero\City of TO - SFEF Application - RPTR LLC.docx CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2
2. Do
you or your organization, or any agency or representative on behalf of you or your organization, anticipate or plan to make any campaign contributions of more than $250 (aggregated) to any City Council member in the 12 months following any City Council action related to this proposal/application? ** There may be legal restrictions on making contributions during the 12 months following City Council Action. It is recommended that you consult with your own legal counsel regarding the requirements of law.
☐ YES
☒ NO
Council Member Name Payee Name Payment Date Payment Amount Ans
wering “YES” to either question above does not preclude the City of Thousand Oaks from entering into or taking any subsequent action related to this proposal/application. However, it may preclude the identified Council member(s) from participating in any actions/decisions related to this proposal/application.
10/3/24 Bryan McQueeney, CEO Rancho Potrero Trail Rides, llc Date Printed Name/ Title of
Authorized
Representative
Name of
Business/ Legal
Entity
Signature*
*S
ignature Policy: The City will accept actual wet signature, scanned copy of actual wet signature, or a verified digital signature from DocuSign or Adobe. Electronic signatures that are NOT digitally verified through DocuSign or Adobe will not be accepted. The application must be signed to be deemed complete. **
*You must submit a supplemental form if you make any new reportable contribution(s) while the proposal/ application is being considered***
** “Aggregated” contributions, as described in FPPC Regulation §18438.5, include the following types of contributions made during a 12 -month period: (1) all contributions made by the party or participant; (2) all contributions made by an agent of the party or participant; and (3) all CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15/\\ch-fs1-p\data\COMMON\Community Grants\2024-25 Grants\Sports\Applicants\Ride On\City of TO - SFEF Application - RO Round Pen.docx
5. E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
California Gov ernment Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council
member from participating in any action related to a contract, agreement, or franchise agreement
(excluding labor or competitively bid contracts) if the Council member receives a campaign
contribution totaling more than $250 (aggregated) from the party to the contract, agreement
or franchise agreement, their agents, or any financially interested participant who actively
supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months
by the party to the agreement, contract, or franchise agreement and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Lev ine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒ The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the required disclosure is set forth below:
1. Hav
e you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
☒ NO
Council Member Name Payee Name Payment Date Payment Amount CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommenda tions\Levine Act Disclosure Form Attachment 3
481-15/\\ch-fs1-p\data\COMMON\Community Grants\2024-25 Grants\Sports\Applicants\Ride On\City of TO - SFEF Application - RO Round Pen.docx CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2
2. Do
you or your organization, or any agency or representative on behalf of you or your organization, anticipate or plan to make any campaign contributions of more than $250 (aggregated) to any City Council member in the 12 months following any City Council action related to this proposal/application? ** There may be legal restrictions on making contributions during the 12 months following City Council Action. It is recommended that you consult with your own legal counsel regarding the requirements of law.
☐ YES
☒ NO
Council Member Name Payee Name Payment Date Payment Amount Ans
wering “YES” to either question above does not preclude the City of Thousand Oaks from entering into or taking any subsequent action related to this proposal/application. However, it may preclude the identified Council member(s) from participating in any actions/decisions related to this proposal/application.
10/2/24 Bryan McQueeney, CEO Ride On LA
Date Printed Name/ Title of
Authorized
Representative
Name of
Business/ Legal
Entity
Signature*
*S
ignature Policy: The City will accept actual wet signature, scanned copy of actual wet signature, or a verified digital signature from DocuSign or Adobe. Electronic signatures that are NOT digitally verified through DocuSign or Adobe will not be accepted. The application must be signed to be deemed complete. **
*You must submit a supplemental form if you make any new reportable contribution(s) while the proposal/ application is being considered***
CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Gra nt CFRC Recommendations\Levine Act Disclosure Form Attachment 3
481-15//Users/adelgadillo/Downloads/1Community Grants Application 9.3.2024.final.docx E. CAMPAIGN CONTRIBUTIONS DISCLOSURE FORM
LEVINE ACT DISCLOSURE FORM
California Government Code section 84308 (Levine Act) prohibits any Thousand Oaks City Council member from participating in any action related to a contract, agreement, or franchise agreement (excluding labor or competitively bid contracts) if the Council member receives a campaign contribution totaling more than $250 (aggregated) from the party to the contract, agreement or franchise agreement, their agents, or any financially interested participant who actively supports or opposes the matter within the previous twelve (12) months. Council members must also disclose any eligible campaign contribution received on the record of the proceeding.
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $250 (aggregated) from a party, their agent/representative, or a financially interested participant during a proceeding and for 12 months following the date a final decision is made. In addition, a party, their agent/representative, or a financially interested participant is prohibited from contributing more than $250 (aggregated) to a Council member during a proceeding and for 12 months following the date a final decision is made.
The Levine Act also requires parties to certain contracts, agreements, or franchise agreements to disclose any campaign contribution over $250 (aggregated) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreement and their agents. The Levine Act does not apply to competitively bid, labor, or personal employment contracts. ☐ The Levine Act (Gov Code § 84308) DOES NOT apply to this proposal/application ☒
required disclosure is set forth below:
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $250 (aggregated) to any council member in the 12 months preceding the date you submitted your proposal/application, the date you completed this form, or the anticipated date of any Council action related to this proposal/application? ☐ YES
◼ NO
Council Member Name Payee Name Payment Date Payment Amount CAO:650-90/tmn/Legal Files\Levine Act – Applications; Page 2 of 2 The Levine Act (Gov Code § 84308) DOES apply to this proposal/application and the CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3
10-3-2024 Senior Development Officer Boys & Girls Clubs of Greater Conejo Valley CCS:483-10\H:\COMMON\Community Services\City Council\Council Items\2024 Staff Reports\12032024\Community Sports Grant CFRC Recommendations\Levine Act Disclosure Form Attachment 3