DISCLOSURE STATEMENTS
The following disclosure & statement apply to the Bidder/Proposer/Contractor/Consultant/Vendor/Supplier or Company:
1. submitting a bid or proposal in response to a solicitation by City of Visalia; or
2. as Awardee of a contract/purchase order which is subject to approval by the Visalia City Council.
OWNERSHIP DISCLOSURE
_________________________________________________________________ Name of Bidder/Proposer/Contractor/Consultant/Vendor/Supplier or Company
_________________________________________________________________ Address
List the names of all principals, partners, and/or trustees. For corporations, provide names of officers, directors and all stockholders owning more than 10% equity interest in corporation:
_____________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
CALIFORNIA LEVINE ACT STATEMENT
California Government Code Section 84308, also known as the “Levine Act,” can prohibit members of the Visalia City Council from participating in any action related to a contract if he or she receives any political contributions totaling more than $250 within the previous twelve (12) months, and for twelve (12) months following the date a final decision concerning the contract has been made, from the person or company awarded the contract. The Levine Act also requires disclosure of such contribution(s) by a party to be awarded a specific contract.
The following website contains a list of current Visalia City Council Members, https://www.visalia.city/government/city_council/default.asp. You are responsible for reviewing the names of Visalia City Council Members prior to making the following disclosure:
1. Have you or your company, or any agent on behalf of you or your company, made any political contributions of more than $250 to a Visalia City Council Member in the twelve (12) months preceding the date of the submission of your proposals or the anticipated date of any City Council action related to this contract?
YES:_____ NO:_____ If yes, please identify the City Council Member(s) and date(s) of contribution in the space below:
Council Member(s) Name Date of Contribution(s)
______________________________ ________________________
Answering YES, does not preclude the City of Visalia from awarding a contract to your firm or from taking any subsequent action related to the contract. It does, however, preclude the identified Visalia City Council Member(s) from participating in any actions related to this contract.
NOTICE: The disclosure duty under state law continues for twelve (12) months after the award. If the above information regarding contributions changes during this time after the award, then the awardee is required to update this disclosure form.
_________________________________________________________________________________ Print or Type Name of Bidder/Proposer/Contractor/Consultant/Supplier/Vendor/Company
__________________________________________ ____________________________________ Signature of Company Authorized Individual Print or Type Name of Authorized Individual 4Creeks
324 S. Santa Fe St., Visalia, CA 93291
CEO: Matthew Ainley CPO: Molly Muirhead Director: David De Groot COO: Joel Alipaz CMO: Eric Riley Director: Rose Morgan CFO: Cody Smith Director: Randy Wasnick No stockholders over 10% Matthew Ainley
4Creeks
203