Contribution Declaration Form – Supervisor Hilda L. Solis

Contribution Declaration Form: Social Program Agreement

This form must be completed by applicants for a Social Program Agreement ("SPA") from the County of Los Angeles ("County"). Pursuant to the Levine Act (Government Code section 84308), members of the Board of Supervisors and other elected and appointed County officers are disqualified from and unable to participate in certain proceedings – including those involving certain contracts – if on or after January 1, 2023, the County officer received more than $250 in contributions from the applicant, any paid agent of the applicant, or any financially interested participant who actively supports or opposes a particular decision in the proceeding.

State law requires you to disclose information about contributions made by you, your organization, and agents paid to represent you or your organization. Failure to complete this form in its entirety may result in delays in the processing of, and perhaps even denial of, your SPA application.

Complete each section below. State “none” if applicable.

A. APPLICANT INFORMATION

1) Name of organization:(Required)

2) Does your organization have a parent, subsidiary, or related organization, including a related political organization or committee? If yes, name the organization(s).

3) Name(s) of members of your Board of Directors who receive compensation for their service on your Board:

B. AGENT INFORMATION

4) Name(s) of employees, and/or any other representative (such as an attorney or lobbyist), who are or will be paid to communicate with the County about this SPA:

C. CONTRIBUTIONS

Did anyone above, either individually or on behalf of your organization, contribute more than $250 on or after 1/1/2023 to the Supervisor from whom you have requested the SPA?(Required)

Yes

If yes, provide the following information for each contribution. Attach additional pages if necessary

Name of Contributor:

Amount of Contribution:

Date of Contribution:

This material is intended for use by applicants for a SPA issued by the County of Los Angeles and does not constitute legal advice.
If you have questions about the Levine Act and how it applies to you and your organization, you should call your lawyer or contact the
Fair Political Practices Commission for further guidance at 1-866-ASK-FPPC (1-866-275-3772) or advice@fppc.ca.gov.