Levine_Act_-_Campaign_Contribution_Disclosure_Form.pdf

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