Attachment_C_-_Campaign_Contribution_Disclosure_Form.docx
DOCX document 37 KB Posted
- Attached to
- Pharmacy Benefits Management Services
- Solicitation number
- 042-1616186-LM
- Issued by
- Orange County, San Francisco City, California
About this file
The document is a Campaign Contribution Disclosure Form for the County of Orange, specifically designed to track and disclose campaign contributions made to Board of Supervisors members or County Agency Officers within the preceding 12 months. The form requires applicants to transparently report any financial contributions made by themselves, subcontractors, agents, or lobbyists to specific county officials, with a requirement to aggregate contributions and provide precise details including contributor names, dates, and amounts.
In conjunction with the disclosure form, the related state and local contract opportunity involves Pharmacy Benefits Management Services for the Orange County Health Care Agency. The primary objective is to provide medication distribution services to Orange County residents of all ages who meet medical necessity criteria and lack alternative financial resources. The program aims to support residents' healthcare needs by ensuring access to essential medications, with service availability contingent upon existing resources. The disclosure form serves as a transparency mechanism to prevent potential conflicts of interest in the procurement process for these critical healthcare services.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment_III_-_Budget_Forms_(ACTUAL_COSTS).xlsx | XLSX spreadsheet | |
| Attachment_I_–_Contract_Template.pdf | ||
| 042-1616186-LM_-_Pharmacy_Benefits_Management_Services.pdf | ||
| Attachment_II_-_Forms_A-E.xlsx | XLSX spreadsheet |
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Text version
COUNTY OF ORANGE
CAMPAIGN CONTRIBUTION DISCLOSURE FORM
Application or Solicitation Number:
Application or Solicitation Title:
Was a campaign contribution, regardless of the dollar amount, made to any member of the Orange County Board of Supervisors or to any County Agency Officer within the preceding 12 months by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist?
Yes ____ No_____
If no, please sign and date below.
If yes, please provide the following information:
Applicant’s Name:
Contributor or Contributor Firm’s Name:
Contributor or Contributor Firm’s Address:
Is the Contributor:
| o | The Applicant | Yes___ | No ___ | |
| o | Subcontractor | Yes___ | No ___ | |
| o | The Applicant’s agent/ or lobbyist | Yes___ | No ___ |
Note: Under California law as implemented by the Fair Political Practices Commission, campaign contributions made by the Applicant and the Applicant’s agent/lobbyist who is representing the Applicant in this application or solicitation must be aggregated together to determine the total campaign contribution made by the Applicant.
Identify the Board of Supervisors Member(s) and County Agency Officer(s) to whom you, your subcontractors, and/or agent/lobbyist made campaign contributions, the name of the contributor, the dates of contribution(s) in the preceding 12 months and dollar amount of the contribution. Each date must include the exact month, day, and year of the contribution.
Name of Board of Supervisors Member or County Agency Officer:
Name of Contributor:
Date(s) of Contribution(s):
Amount(s):
(Please add an additional sheet(s) to identify additional Board Members or County Agency Officer to whom you, your subconsultants, and/or agent/lobbyist made campaign contributions)
By signing below, I certify that the statements made herein are true and correct. I also agree to disclose to the County any future contributions made to Board Members or County Agency Officers by the applicant, or, if applicable, any of the applicant’s proposed subcontractors or the applicant’s agent or lobbyist after the date of signing this disclosure form, and within 12 months prior to and following the approval, renewal, or extension of the requested license, permit, or entitlement to use.
Date Signature of Applicant
| _______________________________________ | ________________________________ | |
| Print Firm Name, if applicable | Print Name of Applicant |
ORANGE COUNTY BOARD OF SUPERVISORS
AND COUNTY AGENCY OFFICERS
Board of Supervisors
Doug Chaffee, Chairman, Fourth District Donald P. Wagner, Vice Chairman, Third District Andrew Do, First District Katrina Foley, Second District, Supervisor-Elect, Fifth District Lisa A. Bartlett, Fifth District Vicente Sarmiento, Supervisor-Elect, Second District
County Agency Officers Claude Parrish, Assessor Hugh Nguyen, Clerk-Recorder Todd Spitzer, District Attorney-Public Administrator Don Barnes, Sheriff-Coroner Shari A. Freidenrich, Treasurer-Tax Collector Andrew Hamilton, Auditor-Controller-Elect
File details come from the government source that posted it. Updated .