Attachment_A_-_Disclosure_Questions_Form.docx

ATTACHMENT A DISCLOSURE QUESTIONS

Instructions: Please respond completely to each question listed below. Use a separate sheet of paper to explain if the answer is marked “YES”. Do not leave a question blank or state “N/A”. If the Applicant1 is an individual, then the information relative to that individual should be disclosed. If the Applicant is a group or joint venture, then information relative to each member of the group or entities that comprise the joint venture should be disclosed. If the Applicant is a corporation, then the information relative to the corporation should be disclosed.

1. Has Applicant ever defaulted on a loan or other financial obligation? This includes all affiliate corporations and partnerships in which applicant is a general partner. If so, use a separate sheet to describe the circumstances including dates and current status.

Answer: NO YES

2. Are there any prior or pending legal proceedings, actions, convictions or judgments that have been filed against Applicant or its wholly owned subsidiaries, or any prior or pending arbitrations or mediations. If so, use a separate sheet to provide dates the complaints were filed and the present status of the litigation or the status of the arbitrations or mediations.

Answer: NO YES

3. Are there any prior or pending administrative complaint/hearing against or any debarment or suspension of or other administrative determination by any federal, state or local government entity relating to Applicant, against any of Applicant’s affiliated corporations or partnerships in which Applicant is a general partner, or other business entity. If so, use a separate sheet to describe the circumstances including dates, agency or body conducting the investigation or inquiry and the current status.

Answer: NO YES

4. Has applicant or its wholly owned subsidiaries ever filed for bankruptcy. Please include dates and jurisdiction of filing, the reason, and current status.

Answer: NO YES

1 For the purposes of this RFP, the term “Applicant” shall mean and refer to the respondent to this RFP regardless of legal form. Thus, applicant applies to individuals, sole proprietorships, joint ventures, unincorporated associations, partnerships, LLCs, LLPs, corporations (whether for profit, nonprofit, California or out of state) and any other entity legally entitled to do business in the State of California.

County of San Mateo – June 2018

5. Describe any business, property, gifts, loans, investments or other financial relationships the Applicant, its individual principals, corporation, LLC, LLP or any of Applicant’s affiliated corporations or partnerships in which Applicant is a general partner, has with any employee of the Housing Authority of the County of San Mateo or member of the Board of Supervisors of the County of San Mateo, or with his/her immediate family, which are financial interest as defined by Section 87103 of the Fair Political Practices Act.2

Answer: NONE YES, SEE DESCRIPTION

Applicant(s) hereby certify under penalty of perjury under the laws of the State of California that all information provided in the Disclosure Questionnaire is true and correct.

Date: Signed:

Name: (Print)

Title:

2 In summary Government Code Section 87100 requires any public officials participating in making decisions to refrain from using their official position to influence a governmental decision in which they know or has reason to know they have a financial interest. Section 87103 defines a financial interest as one that has a material, financial effect on the official or a member of their immediate family as follows: business interest – over $2,000; real property interest – over $2,000; other source of income within 12 months before the decision – over $500; gift or intermediary for donor of gift within 12 months

- $250; business entity in which the official is a director, officer, partner, trustee, employee or holds a position of management. See Government Code Section 87103 for the complete definition.