Please respond to each paragraph individually, attaching additional information as needed.

Provide the names and titles of all individuals providing professional services to the City of including advisors and subcontractors, if any. After each name, please provide the responsibilities of that person with regard to the professional services provided to the City.
1. List the names of any of the above individuals who are current or former officials or employees of the City and their position; and
2. List the names of any of the above individuals who has been a registered federal or state lobbyist and the date of the most recent renewal/registration.
Within the last 10 years, have any of the individuals identified above been employed by the City. If yes, please identify the individual’s name, position with the City, and dates of employment.
Within the last 10 years, has the Respondent employed or paid compensation to a third party intermediary, agent, or lobbyist to directly or indirectly communicate with any City official in connection with any transaction or investment involving the Respondent and the City. This question does not apply to any officer or employee of the Respondent who is acting within the scope of the Respondent’s standard professional duties on behalf of the Respondent including the actual provision of legal, accounting, engineering, real estate, or other professional advice, services, or assistance pursuant to its professional services contract with the City.
Within the last 10 years, has any agent, officer, director, or employee of the Respondent solicited a third party to make a political contribution to any City official; any candidate for municipal office in the City; any local, county, or district political party of such official or candidate; or any political committee of such official or candidate. If yes, please identify the agent, officer, director, or employee who made the solicitation; the individual or individuals who were solicited; and the municipal officers, candidates, political party, or political committee for whom the solicitation was made.
Within the last 10 years, has the Respondent made any contribution to a City official or candidate for municipal office in the City. If yes, please identify the recipient, the amount, and the date of the contribution.
Does the Respondent have a direct financial, commercial, or business relationships with any City official. With regard to every City official for which the answer is yes, identify that individual and provide a detailed written description of that relationship.
Within the last 10 years, has the Respondent conferred any gift of more than nominal value to any City official. A gift includes money, services, loans, travel, and entertainment, at value or discounted value. With regard to every City official for which the answer is yes, identify the recipient, the gift, and the date it was conferred.
Did the Respondent make political contributions the meet all of the following four criteria:
1. The contribution was made within the last 10 years;
2. The contribution was made by an officer, director, executive-level employee, or owner of at least five percent (5%) of the Respondent;
3. The amount of the contribution was at least $500.00 in the form of either a single contribution by an officer, director, executive-level employee, or owner of at least five percent (5%) or the aggregate of all contributions by all officers, directors, executive-level employees, and owners of at least five percent (5%); and
4. The contribution was made to a candidate for any public office of the City, or County, or of a district within or containing the City; to an individual who holds such office; or to a political committee of such candidate or office-holder. If yes, then the Respondent shall provide the following information: the name and address of the contributor, the contributor’s relationship to the Respondent, the name and office or position of each recipient, the amount of the contribution, and the date of the contribution.
Regarding the provision of professional services to the City, are you aware of any conflicts of interest, whether apparent, potential, or actual, with respect to any officer, director, or employee of the Respondent and officials or employees of the City. If yes, please provide a detailed written explanation of the circumstances which you believe provide a basis to conclude that an apparent, potential, or actual conflict of interest may exist.
Please provide the name(s) and person(s) completing this form. At least one of the individuals identified by the Respondent in the first paragraph must participate in completing this form and must sign the verification statement below.

VERIFICATION

I, ___________________________, hereby state that I am ______________________ for _____________________________, and am authorized to make this verification.

I verify that the facts set forth in the foregoing Act 44 Disclosure Form for entities providing professional services to the City, and any relating attachments, are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to penalties of 18 P.A.C.S section 4904 relating to unsworn falsification to authorities.

Signed: ______________________________ Date:__________________________

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