Ci" of ----
Thousund Oaks
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 $500 (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 $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?
0 YES Levine Act applies. Continue to questions 1 & 2 and certification.
D 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?
D YES
0 NO
Council Member Name Payee Name Payment Date Payment Amount ATTACHMENT #5
DPW: 821-60\ev\Council\2025\040825\Summary Vacation Water E asement Att 5.pdf
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 $500 (aggregated*) to any City Council member in the 12 months following any City Council action related to this Agreement/Contract? ** 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
El NO
Coun cil 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. 12-18-24
Date
Ron Mertzel, VP Planning/Development
Printed Name/Title of Authorized
Representative
ThousandOaksMultifamilyLLC
Name of Business/Legal
Entity
Ron Mertzel
Digitally signed by Ron Mertzel
Date: 2024.12.18 10:27:33 -08'00'
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; o r (2) all contributions made by an individual or entity required to be aggregated with the party or participant. Contributions made by agents of the party are not included in the aggregation.
2