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CITY OF SANTA ANA <br />meraencv Shelter Grant <br />Federal, state and city law prohibits employees and public officials of the City of Santa Ana from participating in any <br />transaction, on behalf of the City, in which they have a financial interest. In order to assure compliance with this <br />requirement, this questionnaire must be completed and submitted by each applicant for Emergency Shelter Grant (ESG) <br />funding. The purpose of this questionnaire is to determine if your agency staff or Board members perform functions or <br />responsibilities that would be a conflict of interest with respect to the ESG program. If necessary, detailed explanations <br />may be provided on separate sheets of paper. <br />1. Is /are there any member(s) of your staff, Board of Directors, or other governing body, who is currently, or <br />has /have been within one year of the date of this questionnaire, a City of Santa Ana employee or a member of a <br />City board or commission that has a direct influence on the allocation of ESG funding? ❑ Yes ❑ No <br />If yes, please list the following: <br />Name Position City /Department <br />2. Will the ESG funds requested by the applicant be used to pay the salaries of any of applicant's staff person(s) <br />who is /are, or has /have been within one year of the date of this questionnaire, employed by the City of Santa <br />Ana? ❑ Yes ❑ No <br />If yes, please list the name(s) below and identify the City Department in which each person is employed: <br />Name City /Department <br />3. Will the ESG funds requested by the applicant be used to pay the salaries of any of applicant's staff person(s) <br />who is /are currently, or has /have been within one year of the date of this questionnaire, a member of a City of <br />Santa Ana board or commission that has a direct influence on the allocation of ESG funding? ❑ Yes ❑ No <br />If yes, please list the following: <br />Name: Year(s) <br />Name: Year(s) <br />Name: Year(s) <br />Name: Year(s) <br />4. Will the ESG funds, requested by the applicant, be used to award a contract or subcontract to any individual(s) or <br />business affiliate(s) who is /are currently, or has /have been within one year of the date of this questionnaire, a City <br />of Santa Ana employee or a member of a City board or commission that has a direct influence on the allocation <br />of ESG funding? ❑ Yes ❑ No <br />If yes, please list the name(s): Name: <br />The ESG funds used for reimbursement of rent shall not benefit any employee, agent, consultant, officer, elected official <br />or appointed official of the subrecipient. This prohibition includes leases between an organization and a director, trustee, <br />officer or key employee of the organization or his /her immediate family either directly or through corporations, trusts, or <br />similar arrangements in which they hold a controlling interest. <br />Organization <br />Signature <br />Date <br />21 <br />19D -24 <br />/AVM - r rTiLa'I <br />