ATTACHMENT #4
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 fol!owing 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 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.
I General Manager
e of Authorized
WAXIE Sanitary Supply
Name of Business/Legal
Entity
NOTE: 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; or (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 FIN:201-10\aw\jkb\H:\COMMON\Council\2025\Facilities\07082025 Citywide Janitorial Supply Contract - Attachment 4.docx