ATTACHMENT #3
City of
Thousand Oaks
LEVINE ACT DISCLOSURE FORM
Council members are prohibited from accepting, soliciting, or directing a campaign contribution of more than $500 (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 $500 (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 $500 (aggregated*) within the preceding twelve (12) months by the party to the agreement, contract, or franchise agreement. The Levine Act does not apply to competitively bid, labor, or personal employment contracts.
Is your grant request $50,000 or greater?
YES Levine Act applies. Continue to questions 1 & 2 and certification.
NO Please continue to certification.
1. Have you or your company, or any agent on behalf of you or your company, made campaign contributions totaling more than $500 (aggregated") to any council member in the 12 months preceding the date you submitted your proposal, the date you completed this form, or the anticipated date of any Council action related to this Agreement/ Contract?
YES
NO
Council Member Name Payee Name Payment Date Payment Amount DPW: 810-40lev|Council20241012825 Limited Franchise Solid Waste Rate Adjustment Att 3.pdf
2. organization, anticipate
be legal restrictions on making contributions during the 12 months following City Council Action. It is recommended that you consult with your own • YES
NO
Council Member Name Payee Name Payment Date Payment 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 Agreement/Contract. However, it may preclude the identified Council member(s) from participating in any actions/decisions related to this Agreement/Contract.
I, the undersigned, certify that the information provided is complete and accurate to the best of my knowledge. I understand that knowingly providing false information constitutes fraud and is punishable under State of California law and under Federal law.
JOSEPH BRAJEVICH
12/19/24
Date Printed Name/Title of Authorize‹
Representative Entity
Signature
NOTE: You must submit a supplemental form If you make any new reportable contribution(s) while the Agreement/Contract 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; or (2) all contributions made by an individual or entity required to be aggregated with participant. Contributions made by agents of the party are not included in the aggregation.