EXHIBIT "B-4"
OWNERSHIP DISCLOSURE AND CALIFORNIA LEVINE ACT STATEMENT The following disclosure and 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 Submit with Bid
2. as Awardee of a contract/purchase order which is subject to approval by the Visalia City Council.
I OWNERSHIP DISCLOSURE
CLAt:lk Pes-r CONTII-OL Of STO::.l,c.TON . I NCName 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 the corporation:
I CALIFORNIA LEVINE ACT STATEMENT
California Govemment Code Section 84308, also know 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 $500 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/qovemment/city council/default.asQ. 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 $500 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. lf the above information regarding contributions changes during this time after the award, then the awardee is required to update this disclosure form.
CL~R.'C. P~!»""t'" Cot.J"T~0~'- OF ~loc;.ierC?N . \NC..
Print or Type Na . • • Bidder/Proposer/Contractor/Consultant/Supp1ierNendor/Company ~ 10 I,{~ 411
Print or Type Name of Authorized Individual
RFB NO. 25-26-32
Annual Contract for Pest Control Services
Facilities Division
Page6