Individual: Campaign Contribution Disclosure Form

Disclosure Forms

Directions:

Please read the following information regarding the completion of these disclosure forms. Please review the definitions prior to completing any form.
Date and initial the top of each form after you have completed it and sign the form on the last page.
NOTE: There are two different types of campaign contribution disclosure forms: one for those who are applying as individuals and one for those applying as businesses. Only fill out one type of form. (If you have used a consultant with respect to applying for this non-competitively bid contract you will have to fill out a campaign contribution disclosure form for them as well.)

Getting Started

There are five sets of disclosure forms enclosed in this packet. You must provide information for each disclosure form. The information you must disclose includes:

Any contributions (defined as a provision of money, in-kind assistance, discounts, forbearance or any other valuable thing) made during the two years prior to the application deadline for this non-competitively bid contract opportunity;
The name of any consultant(s) you used to help in obtaining the non-competitively bid contract and any campaign contributions they have made during the two years prior to the application deadline;
Any subcontractors you are planning to use if awarded this contract;

4. Whether a Fund for Philadelphia employee or official asked you to give money, services, or any other thing of value to any individual or entity; and

5. Whether a Fund for Philadelphia employee or official gave you any advice on how to satisfy any minority, women, disabled or disadvantaged business participation goals.

More information on Disclosing Campaign Contributions

Applicants for contract opportunities must disclose any contributions they made to:

- A candidate for nomination or election in any public office in the Commonwealth of Pennsylvania

- An incumbent in any public office in the Commonwealth of Pennsylvania

- A political committee or state party in the Commonwealth of Pennsylvania

- A group, committee, or association organized in support of any candidate, office holder, political committee or state party in the Commonwealth of Pennsylvania

Attribution Rules. In addition to disclosing contributions made directly by the applicant, the applicant will be asked to supply information on other types of contributions. The campaign contribution disclosure forms will include questions that specifically ask for information on these other types of contributions. These contributions will be attributed to the individual or business and will be used to determine the applicant’s eligibility to be awarded a contract.

Businesses (i.e. corporation, limited liability company, partnership association, joint venture, or any other legal entity) have to disclose contributions made by the following:

- Applicant business

- Parent, subsidiary, or otherwise affiliated entity of the applicant business (“affiliate”)

- An individual or business that is then reimbursed by the applicant business or affiliate

- Officers, directors, controlling shareholders, or partners of the for-profit applicant business or for-profit affiliate

- Political action committee controlled by applicant business or affiliate

- Political action committee controlled by officer, director, controlling shareholder, or partner of the for-profit applicant business or for-profit affiliate

Individuals have to disclose contributions made by the following:

- Applicant individual

- Member of individual’s immediate family (i.e., spouse, life partner, or dependent child living at home), when contributions are in excess of $2600

In addition to direct contributions to candidates, incumbents, or political committees in the Commonwealth of Pennsylvania, applicants are also required to disclose:

Contributions not directly given to a candidate, incumbent, or political committee but made with the intent that the contribution will benefit the candidate, incumbent, or political committee;
Solicitation of contributions on behalf of a candidate, incumbent, or political committee, including the hosting of or solicitation at fundraising events (required to disclose details regarding the date of event and amount raised); and
Contributions not made directly by the individual/business to a candidate, incumbent, or political committee but furnished by the individual / business (as an “intermediary”).

Eligibility Restrictions

If an individual makes contributions totaling over $2,600 in one calendar year to a candidate for City elective office or to an incumbent, the individual is not eligible to receive a non-competitively bid contract during that candidate’s or incumbent’s term of office.

If a business makes contributions totaling over $10,600 in one calendar year to a candidate for City elective office or to an incumbent, the business is not eligible to receive a non-competitively bid contract during that candidate’s or incumbent’s term of office.

Although individuals and businesses have to disclose campaign contributions made during the two years prior to the deadline for completing these forms, the eligibility restrictions take into consideration only those contributions made on or after January 1, 2006.

à Note on Eligibility: If a candidate for any City elective office contributes $250,000 or more from his or her personal resources to his or her campaign, then the eligibility thresholds for individuals and businesses shall double with respect to contributions to all candidates for that same elective office (i.e. $5,200 for individuals and $21,200 for businesses).

Definitions

Affiliate	A parent, subsidiary, or otherwise affiliated entity of a business
Applicant	An individual or business who has filed an application to be awarded a non- competitively bid contract
Business	A corporation, limited liability company, partnership, association, joint venture or any other legal entity (including non-profit organizations) that is not an Individual
Candidate	Any individual who seeks nomination or election to public office, other than a judge of elections or inspector of elections, whether or not such individual is nominated or elected. An individual shall be deemed to be seeking nomination or election to such office if he or she has (1) received a contribution or made an expenditure or has given his consent for any other person or committee to receive a contribution or make an expenditure, for the purpose of influencing his or her nomination or election to such office, whether or not the individual has made known the specific office for which he or she will seek nomination or election at the time the contribution is received or the expenditure is made; or (2) taken the action necessary under the laws of the Commonwealth of Pennsylvania to qualify himself or herself for nomination or election to such office.
Consultant	A person used by an applicant to assist in obtaining a non-competitively bid contract through direct or indirect communication by such individual or business with any City agency or City officer or employee, if the communication is undertaken by such individual or business in exchange for, or with the understanding of receiving, payment from the applicant; provided, however, that “Consultant” shall not include a full-time employee of the applicant.
Contributions	The provision of money, in-kind assistance, discounts, forbearance or any other valuable thing, during the two years prior to the deadline for the filing of the application for the contract opportunity, to any of the following: - a candidate for nomination or election to any public office in the Commonwealth of Pennsylvania; - an incumbent in any public office in the Commonwealth; - a political committee or state party in the Commonwealth; or - a group, committee or association organized in support of any candidate, office holder, political committee or state party in the Commonwealth.
Immediate family	A spouse or life partner residing in the individual’s household or minor dependent children
Incumbent	An individual who holds elective office
Intermediary	A person, who, other than in the regular course of business as a postal, delivery or messenger service, delivers a contribution from another individual or business to the recipient of such contribution
Non-Competitively Bid Contract	A contract for the purchase of goods or services to which the City or City Agency is a party that is not subject to the lowest responsible bidder requirements of Section 8-200 of the Home Rule Charter, including, but not limited to, a Professional Services Contract, and any renewal of such a contract (other than a renewal term pursuant to an option to renew contained in an executed contract)
Person	An individual, corporation, limited liability company, partnership, association, joint venture, or any other legal entity
Political committee	Any committee, club, association or other group of persons which receives money or makes expenditures for purposes of influencing any election
Professional Services Contract	A contract to which the City or a City Agency is a party that is not subject to the lowest competitive bidding requirements of Section 8-200 of the Home Rule Charter because it involves the rendition of professional services, including any renewal of such a contract (other than a renewal term pursuant to an option to renew contained in an executed contract)
Solicit a Contribution	Requesting or suggesting that a person make a contribution. The sponsoring or hosting of a fundraising event is considered soliciting a contribution from the attendees of the event. Any contributions raised at such event are counted as a contribution made by the host of the event.

If Applying as an Individual:

Campaign Contribution Disclosure Form

For relationship, please indicate whether the contributor was the Individual or Family Member.

Name of Contributor	Relationship (to individual or business completing this form)	Name of Recipient	Date of Contribution	Amount of Contribution

Please use additional pages as needed.

If Applying as a Business:

Campaign Contribution Disclosure Form

Please read through the directions and definitions before filling out this disclosure form to make sure that each question is answered appropriately and thoroughly. Where “non-profit” is an option, indicate whether the business is a non-profit; non-profits are not required to disclose contribution information on these questions. Note that you must provide information for the two years prior to the application deadline.

	Yes	No	Non-Profit
Has the business made any contributions?
Has the business solicited or served as an intermediary for any contributions?
Has an officer, director, controlling shareholder, or partner of the business made any contributions? See note below.
Has an officer, director, controlling shareholder, or partner of the business solicited or served as an intermediary for any contributions? See note below.
Has an affiliate of the business made any contributions?
Has an affiliate of the business solicited or served as an intermediary for any contributions?
Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of the business made any contributions? See note below.
Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of the business solicited or served as an intermediary for any contributions? See note below.
Has the business or an affiliate of the business reimbursed another individual or business for a contribution that the individual or business has made?
Has an officer, director, controlling shareholder, or partner of a for-profit business, or of a for-profit affiliate of the business, reimbursed another individual or business for a contribution that the individual or business has made?
Has a political committee controlled by the business or by an affiliate of the business made any contributions?
Has a political committee controlled by an officer, director, controlling shareholder, or partner of the for-profit business, or of a for-profit affiliate of the business, made any contributions?
Check here to certify that no contributions were made.

Note: Applicants must disclose all contributions to candidates or incumbents which are attributed to an immediate family member of an officer, director, controlling shareholder or partner of the for-profit Applicant or the for-profit affiliate of the Applicant. Please disclose the full amount of the contribution, although only the amount above $2600 will be attributed to the officer, director, controlling shareholder or partner (and, by extension, the Applicant business).

Additional information on every contribution must be disclosed.

Please use the table provided on the next page.

If Applying as a Business:

Campaign Contribution Disclosure Form

For relationship, indicate whether the contributor was the Business, Affiliate, Controlled Political Committee, Controlling Shareholder, Director, Officer, Parent, Partner, Reimbursed Contributor, Solicited Contributor, Subsidiary, or Other.

Name of Contributor	Relationship (to individual or business completing this form)	Name of Recipient	Date of Contribution	Amount of Contribution

Please use additional pages as needed.

Use of Consultant Disclosure Form

Please list all consultant(s) used in the year prior to the application deadline for this contract opportunity and the corresponding information for that consultant in the space provided below.

Please note that a Consultant, for the purposes of the required disclosures, is defined as an individual or business used by an applicant or contractor to assist in obtaining a non-competitively bid contract through direct or indirect communication by such individual or business with the Fund for Philadelphia or any Fund for Philadelphia employee or official, if the communications is undertaken in exchange for, or with the understanding of receiving, payment from the applicant or contractor or any other individual or business (however, “Consultant” shall not include a full-time employee of the Applicant or Contractor).

Check here to certify that no consultant(s) was used in the year prior to the application deadline for this contract opportunity.

Consultant Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid

Consultant Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid

Consultant Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid

Consultant Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid

Consultant: Individual Campaign Contribution Disclosure Form

Use this form if the Consultant used is an Individual. Please read through the directions and definitions before filling out this disclosure form to make sure that each question is answered appropriately and thoroughly. Note that you must provide information for the two years prior to the application deadline.

	Yes	No
Has the Consultant made any contributions?
Has the Consultant solicited or served as an intermediary for any contributions?
Has a member of the Consultant’s immediate family made any contributions over and above $2,600?
Has a member of the Consultant’s immediate family solicited or served as an intermediary for contributions over and above $2,600?
Check here to certify that no contributions were made.

Additional information on every contribution must be disclosed.

Please use the table provided on the next page.

Consultant: Individual Campaign Contribution Disclosure Form

Use this form if the Consultant used is an Individual. For relationship, indicate whether the contributor was the Individual or Family Member. .

Name of Contributor	Relationship to Consultant	Name of Recipient	Date of Contribution	Amount of Contribution

Please use additional pages as needed.

Consultant: Business Campaign Contribution Disclosure Form

Use this form if the Consultant used is a Business. Please read through the directions and definitions before filling out this disclosure form to make sure that each question is answered appropriately and thoroughly. Where “non-profit” is an option, indicate whether the business is a non-profit; non-profits are not required to disclose contribution information on these questions. Note that you must provide information for the two years prior to the application deadline.

	Yes	No	Non-Profit
Has the Consultant business made any contributions?
Has the Consultant business solicited or served as an intermediary for any contributions?
Has an officer, director, controlling shareholder, or partner of the Consultant business made any contributions? See note below.
Has an officer, director, controlling shareholder, or partner of the Consultant business solicited or served as an intermediary for any contributions? See note below.
Has an affiliate of the Consultant business made any contributions?
Has an affiliate of the Consultant business solicited or served as an intermediary for any contributions?
Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of the Consultant business made any contributions? See note below.
Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of the Consultant business solicited or served as an intermediary for any contributions? See note below.
Has the Consultant business or an affiliate of the business reimbursed another individual or business for a contribution that the individual or business has made?
Has an officer, director, controlling shareholder, or partner of the for-profit Consultant business, or of a for-profit affiliate of the Consultant business, reimbursed another individual or business for a contribution that the individual or business has made? See note below.
Has a political committee controlled by the Consultant business or by an affiliate of the business made any contributions?
Has a political committee controlled by an officer, director, controlling shareholder, or partner of the for-profit Consultant business, or of a for-profit affiliate of the Consultant business, made any contributions?
Check here to certify that no contributions were made.

Note: Consultants must disclose all contributions to candidates or incumbents which are attributed to an immediate family member of an officer, director, controlling shareholder or partner of the for-profit Consultant or the for-profit affiliate of the Consultant. Please disclose the full amount of the contribution, although only the amount above $2600 will be attributed to the officer, director, controlling shareholder or partner (and, by extension, the Consultant business).

Additional information on every contribution must be disclosed.

Please use the table provided on the next page.

Consultant: Business Campaign Contribution Disclosure Form

Use this form if the Consultant used is a Business. For relationship, indicate whether the contributor was the Consultant Business, Affiliate, Controlled Political Committee, Controlling Shareholder, Director, Officer, Parent, Partner, Reimbursed Contributor, Solicited Contributor, Subsidiary, or Other.

Name of Contributor	Relationship to Consultant	Name of Recipient	Date of Contribution	Amount of Contribution

Please use additional pages as needed.

Use of Subcontractor Disclosure Form

Please list all subcontractor(s) you are planning to use if awarded this non-competitively bid contract by filling out the appropriate information in the space provided below.

Check here to certify that no subcontractor(s) are to be used.

Subcontractor Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid, or Percentage to be Paid

Subcontractor Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid, or Percentage to be Paid

Subcontractor Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid, or Percentage to be Paid

Subcontractor Name
Address 1
Address 2
City, State, Zip
Phone
Amount Paid or to be Paid, or Percentage to be Paid

Employee Request Disclosure Form

Please list any Fund for Philadelphia employees or officers who have asked you (the Applicant), any officer director, or management employee of the Applicant, or any person representing the Applicant to give money, services, or any other thing of value (other than contributions as defined above) during the two years prior to the application deadline for this contract opportunity.

Check here to certify that no Fund for Philadelphia employees or officers who have asked you (the Applicant), any officer director, or management employee of the Applicant, or any person representing the Applicant to give money, services, or any other thing of value (other than contributions as defined above) during the two years prior to the application deadline for this contract opportunity.

Name of Employee/Officer
Title
Money Services, or Thing of Value Requested
Money, Services, or Thing of Value Given (If none, write “none”)
Date Requested
Date of Payment

Name of Employee/Officer
Title
Money Services, or Thing of Value Requested
Money, Services, or Thing of Value Given (If none, write “none”)
Date Requested
Date of Payment

Name of Employee/Officer
Title
Money Services, or Thing of Value Requested
Money, Services, or Thing of Value Given (If none, write “none”)
Date Requested
Date of Payment

Employee Participation Advice Disclosure Form

Please list any Fund for Philadelphia employees or officers who gave you (the Applicant), any officer director, or management employee of the Applicant, or any person representing the Applicant advice that a particular individual or business could be used by the Applicant to satisfy any goals established in the contract for the participation of minority, women, disabled, or disadvantaged business enterprises during the two years prior to the application deadline for this contract opportunity.

Check here to certify that no Fund for Philadelphia employees or officers gave you (the Applicant), any officer director, or management employee of the Applicant, or any person representing the Applicant advice that a particular individual or business could be used by the Applicant to satisfy any goals established in the contract for the participation of minority, women, disabled, or disadvantaged business enterprises during the two years prior to the application deadline for this contract opportunity.

Name of Employee/Officer
Title
Date of Advice
Individual or Business Recommended to Satisfy Participation Goals

Name of Employee/Officer
Title
Date of Advice
Individual or Business Recommended to Satisfy Participation Goals

Name of Employee/Officer
Title
Date of Advice
Individual or Business Recommended to Satisfy Participation Goals

Name of Employee/Officer
Title
Date of Advice
Individual or Business Recommended to Satisfy Participation Goals

Signature Page

In order for the submission of these disclosure forms to be considered valid, they must be properly signed below by the respondent. Disclosure forms that are not signed will be rejected. By signing your name and title in the signature space below, you, as the applicant, signify your intent to sign these disclosure forms. The signatory hereby declares and certifies themselves to be the applicant, declares and certifies that they are properly authorized to execute these disclosure forms, and represents and covenants that all of the information and disclosures provided to the best of their knowledge are true and contain no material misstatements or omissions. Breach of such representation and covenant may render any subsequent contract voidable, and entitle the Fund for Philadelphia to all rights and remedies provided by law or equity.

If these disclosure forms are being submitted by an INDIVIDUAL, PARTNERSHIP, LIMITED LIABILITY COMPANY OR MANAGED LIMITED LIABILITY COMPANY, sign the forms here:

Signature Date

Name Title

If these disclosure forms are being submitted by a CORPORATION, sign the forms here, with signatures by (a) President or Vice-President of the corporation AND (b) Secretary, Assistant Secretary, Treasurer or Assistant Treasurer of the corporation. If the disclosure forms are not signed by the above mentioned, you hereby certify that you are authorized pursuant to a certified corporate resolution to sign in place of such officers.

Signature Date

Name President/Vice President, if other, please specify

Signature Date

Name Secretary/Asst. Secretary/Treasurer/Asst. Treasurer

If other, please specify

	Yes	No
Have you made any contributions?
Have you solicited or served as an intermediary for any contributions?
Has a member of your immediate family made any contributions over and above $2,600?
Has a member of your immediate family solicited or served as an intermediary for contributions over and above $2,600?
Check here to certify that no contributions were made.