HomeMy WebLinkAboutService Agreement - Shatanya Nunn signed 002.pdf P-25-182
1 SERVICE AGREEMENT
2 This Service Agreement ("Agreement") is dated 5/6/25 and is between
3 Shatanya Nunn, a sole proprietor("Contractor"), and the County of Fresno, a political
4 subdivision of the State of California("County"),
5 Recitals
6 A. The Perinatal Equity Initiative(PEI) program aims to improve maternal and infant health
7 outcomes and reduce disparities within the Black/African American community by establishing a
B bereavement support group for Black/African American women who have experienced infant or
9 pregnancy loss.
10 B. County, through its Department of Public Health (DPH) PEI program, is in need of a
11 qualified vendor to serve as a facilitator for a culturally appropriate bereavement support group
12 for Black/African American families impacted by the loss of an infant or pregnancy.
13 C. County, through its DPH PEI program,desires to address the disproportionately high
14 infant mortality rate within the Black/African American community in Fresno County by providing
15 a safe, supportive, and culturally sensitive environment for grieving families,
16 D. Contractor has the ability to guide and support grieving families through the grieving
17 process, drawing upon experience and cultural understanding to create a safe and empowering
18 environment for healing,
19 The parties therefore agree as follows:
20 Article 1
21 Contractor's Services
22 1.1 Scope of Services. The Contractor shall perform all of the services provided in
23 Exhibit A to this Agreement, titled "Scope of Services."
24 1.2 Representation. The Contractor represents that it is qualified, ready, willing, and
25 able to perform all of the services provided in this Agreement.
26 1.3 Compliance with Laws. The Contractor shall, at its own cost, comply with all
27 applicable federal, state, and local laws and regulations in the performance of its obligations
28
1
P-25-182
1 under this Agreement, including but not limited to workers compensation, labor, and
2 confidentiality laws and regulations.
3 Article 2
4 County's Responsibilities
5 2.1 The County shall provide appropriate meeting space for all Support Group sessions
6 and planning meetings that is accessible, private, and conducive to the therapeutic activities.
7 2.2 .The County shall coordinate and schedule monthly meetings with the Contractor,
8 MSW Facilitator, and Parent Facilitator.
9 2.3 The County shall serve as the primary point of contact for program coordination and
10 administrative matters, participants RSVPs and attendance tracking, and questions or concerns
11 from participants.
12 2.4 The County shall provide all necessary materials for group facilitations, including but
13 not limited to: grief books/journals, craft supplies, food and refreshments, as approved by the
14 PEI grant funding.
15 2.5 The County shall assist in participant recruitment and referrals through appropriate
16 County channels and community partnerships.
17 2.6 The County shall support community outreach and marketing efforts to ensure
18 program visibility within the focus populations.
19 2.7 The County shall coordinate regular program evaluation activities and collect
20 participant feedback to support continuous quality improvement.
21 Article 3
22 Compensation, Invoices, and Payments
23 3.1 The County agrees to pay, and the Contractor agrees to receive, compensation for
24 the performance of its services under this Agreement as described in this section.
25 3.2 Maximum Compensation.The maximum compensation payable to the Contractor
26 under this Agreement is Three Thousand Two Hundred Forty and No/100 Dollars ($3,240). The
27 Contractor acknowledges that the County is a local government entity, and does so with notice
28 that the County's powers are limited by the California Constitution and by State law, and with
2
P-25-182
1 notice that the Contractor may receive compensation under this Agreement only for services
2 performed according to the terms of this Agreement and while this Agreement is in effect, and
3 subject to the maximum amount payable under this section. The Contractor further
4 acknowledges that County employees have no authority to pay the Contractor except as
5 expressly provided in this Agreement.
6 3.3 Invoices. The Contractor shall submit monthly invoices to the County of Fresno
7 Department of Public Health, Public Health Nursing Division, P.O. Box 11867, Fresno, CA
8 93755, Attention: Division Manager at DPI-IBOAP c fresnocountyca.gov. The Contractor shall
9 submit each invoice within 30 days after the month in which the Contractor performs services
10 and in any case within 45 days after the end of the term or termination of this Agreement.
11 3.4 Payment. The County shall pay each correctly completed and timely submitted
12 invoice within 45 days after receipt. The County shall remit any payment to the Contractor's
13 address specified in the invoice.
14 3.5 Incidental Expenses. The Contractor is solely responsible for all of its costs and
15 expenses that are not specified as payable by the County under this Agreement.
16 Article 4
17 Term of Agreement
18 4.1 Term. This Agreement is effective upon execution and terminates on March 30, 2027
19 except as provided in section Article 6, "Termination and Suspension," below.
20 Article 5
21 Notices
22 5.1 Contact Information. The persons and their addresses having authority to give and
23 receive notices provided for or permitted under this Agreement include the following:
24
For the County:
25 Director, Department of Public Health
County of Fresno
26 P.O. Box11867
Fresno, CA 93775
27 DPHContracts@fresnocountyca.gov
28
3
P-25-182
1 For the Contractor:
Shatanya Nunn
2 2218 N Fresno St.#101
Fresno, CA 93703
3 shatanyan@gmail.com
4 5.2 Change of Contact Information. Either party may change the information in section
5 5.1 by giving notice as provided in section 5.3.
6 5.3 Method of Delivery. Each notice between the County and the Contractor provided
7 for or permitted under this Agreement must be in writing, state that it is a notice provided under
8 this Agreement, and be delivered either by personal service, by first-class United States mail, by
9 an overnight commercial courier service, , or by Portable Document Format(PDF)document
10 attached to an email.
11 (A) A notice delivered by personal service is effective upon service to the recipient.
12 (l3) A notice delivered by first-class United States mail is effective three County
13 business days after deposit in the United States mail, postage prepaid, addressed to the
14 recipient.
15 (C)A notice delivered by an overnight commercial courier service is effective one
16 County business day after deposit with the overnight commercial courier service,
17 delivery fees prepaid, with delivery instructions given for next day delivery, addressed to
18 the recipient.
19 (D)A notice delivered by PDF document attached to an email is effective when
20 transmission to the recipient is completed (but, if such transmission is completed outside
21 of County business hours, then such delivery is deemed to be effective at the next
22 beginning of a County business day), provided that the sender maintains a machine
23 record of the completed transmission.
24 5.4 Claims Presentation. For all claims arising from or related to this Agreement,
25 nothing in this Agreement establishes, waives, or modifies any claims presentation
26 requirements or procedures provided by law, including the Government Claims Act(Division 3.6
27 of Title 1 of the Government Code, beginning with section 810).
28
4
P-25-182
1 Article 6
2 Termination and Suspension
3 6.1 Termination for Non-Allocation of Funds. The terms of this Agreement are
4 contingent on the approval of funds by the appropriating government agency. If sufficient funds
5 are not allocated, then the County, upon at least 30 days' advance written notice to the
6 Contractor, may:
7 (A) Modify the services provided by the Contractor under this Agreement; or
8 (B) Terminate this Agreement.
9 6.2 Termination for Breach.
10 (A) Upon determining that a breach (as defined in paragraph (C) below) has
11 occurred, the County may give written notice of the breach to the Contractor. The written
12 notice may suspend performance under this Agreement, and must provide at least 30
13 days for the Contractor to cure the breach.
14 (B) If the Contractor fails to cure the breach to the County's satisfaction within the
15 time stated in the written notice, the County may terminate this Agreement immediately.
16 (C)For purposes of this section, a breach occurs when, in the determination of the
17 County, the Contractor has:
18 (1) Obtained or used funds illegally or improperly;
19 (2) Failed to comply with any part of this Agreement;
20 (3) Submitted a substantially incorrect or incomplete report to the County; or
21 (4) Improperly performed any of its obligations under this Agreement.
22 6.3 Termination without Cause. In circumstances other than those set forth above, the
23 County may terminate this Agreement by giving at least 30 days advance written notice to the
24 Contractor.
25 6.4 No Penalty or Further Obligation. Any termination of this Agreement by the County
26 under this Article 6 is without penalty to or further obligation of the County.
27 6.5 County's Rights upon Termination. Upon termination for breach under thls Article
28 6, the County may demand repayment by the Contractor of any monies disbursed to the
5
P-25-182
1 Contractor under this Agreement that, in the County's sole judgment, were not expended in
2 compliance with this Agreement. The Contractor shall promptly refund all such monies upon
3 demand, This section survives the termination of this Agreement.
4 Article 7
5 Funding Source
6 7.1 Services Funding Source. Funding for these services is provided by the California
7 Department of Public Health, Perinatal Equity Initiative, through State General Funds that have
8 been authorized through the State of California Health and Safety Code, Section 123260.
9 Article 8
10 Confidentiality
11 8.1 Confidentiality. All services performed by the Contractor under this Agreement
12 shall be in strict conformance with all applicable Federal, State of California and/or local laws
13 and regulations relating to confidentiality.
14 Article 9
15 Independent Contractor
16 9.1 Status. In performing under this Agreement, the Contractor, including its officers,
17 agents, employees, and volunteers, is at all times acting and performing as an independent
18 contractor, in an independent capacity, and not as an officer, agent, servant, employee,joint
19 venturer, partner, or associate of the County.
20 9.2 Verifying Performance. The County has no right to control, supervise, or direct the
21 manner or method of the Contractor's performance under this Agreement, but the County may
22 verify that the Contractor is performing according to the terms of this Agreement.
23 9.3 Benefits. Because of its status as an independent contractor, the Contractor has no
24 right to employment rights or benefits available to County employees. The Contractor is solely
25 responsible for providing to its own employees all employee benefits required by law. The
26 Contractor shall save the County harmless from all matters relating to the payment of
27 Contractor's employees, including compliance with Social Security withholding and all related
28 regulations,
6
P-25-182
1 9.4 Services to Others. The parties acknowledge that, during the term of this
2 Agreement, the Contractor may provide services to others unrelated to the County.
3 Article 10
4 Indemnity and Defense
5 10.1 Indemnity. The Contractor shall indemnify and hold harmless and defend the
6 County(including its officers, agents, employees, and volunteers)against all claims, demands,
7 injuries, damages, costs, expenses (including attorney fees and costs), fines, penalties, and
8 liabilities of any kind to the County, the Contractor, or any third party that arise from or relate to
9 the performance or failure to perform by the Contractor (or any of its officers, agents,
10 subcontractors, or employees) under this Agreement. The County may conduct or participate in
11 its own defense without affecting the Contractor's obligation to indemnify and hold harmless or
12 defend the County.
13 10.2 The Contractor shall complete and sign the"Agreement and Release of Liability"
14 (Exhibit B to this Agreement)and submit to the County before services are provided.
15 10.3 Survival. This Article 10 survives the termination of this Agreement.
16 Article 11
17 Inspections, Audits, and Public Records
18 11.1 Inspection of Documents. The Contractor shall make available to the County, and
19 the County may examine at any time during business hours and as often as the County deems
20 necessary, all of the Contractor's records and data with respect to the matters covered by this
21 Agreement, excluding attorney-client privileged communications, The Contractor shall, upon
22 request by the County, permit the County to audit and inspect all of such records and data to
23 ensure the Contractor's compliance with the terms of this Agreement,
24 11.2 State Audit Requirements. If the compensation to be paid by the County under this
25 Agreement exceeds $10,000, the Contractor is subject to the examination and audit of the
26 California State Auditor, as provided in Government Code section 8546.7,for a period of three
27 years after final payment under this Agreement. This section survives the termination of this
28
7
P-25-182
1 Agreement. Additional Federal audit requirements may apply if any portion of the compensation
2 to be paid by the County under this Agreement is also provided by Federal funding.
3 11.3 Public Records.The County is not limited in any manner with respect to its public
4 disclosure of this Agreement or any record or data that the Contractor may provide to the
5 County, The County's public disclosure of this Agreement or any record or data that the
6 Contractor may provide to the County may include but is not limited to the following:
7 (A)The County may voluntarily, or upon request by any member of the public or
8 governmental agency, disclose this Agreement to the public or such governmental
9 agency.
10 (B)The County may voluntarily, or upon request by any member of the public or
11 governmental agency, disclose to the public or such governmental agency any record or
12 data that the Contractor may provide to the County, unless such disclosure is prohibited
13 by court order.
14 (C)This Agreement, and any record or data that the Contractor may provide to the
15 County, is subject to public disclosure under the Ralph M. Brown Act(California
16 Government Code, Title 5, Division 2, Part 1, Chapter 9, beginning with section 54950).
17 (D)This Agreement, and any record or data that the Contractor may provide to the
18 County, is subject to public disclosure as a public record under the California Public
19 Records Act(California Government Code, Title 1, Division 7, Chapter 3.5, beginning
20 with section 6250)("CPRA").
21 (E) This Agreement, and any record or data that the Contractor may provide to the
22 County, is subject to public disclosure as information concerning the conduct of the
23 people's business of the State of California under California Constitution, Article 1,
24 section 3, subdivision (b).
25 (F) Any marking of confidentiality or restricted access upon or otherwise made with
26 respect to any record or data that the Contractor may provide to the County shall be
27 disregarded and have no effect on the County's right or duty to disclose to the public or
28 governmental agency any such record or data.
8
P-25-182
1 11.4 Public Records Act Requests. If the County receives a written or oral request
2 under the CPRA to publicly disclose any record that is in the Contractor's possession or control,
3 and which the County has a right, under any provision of this Agreement or applicable law, to
4 possess or control, then the County may demand, in writing, that the Contractor deliver to the
5 County, for purposes of public disclosure, the requested records that may be in the possession
6 or control of the Contractor. Within five business days after the County's demand, the
7 Contractor shall (a) deliver to the County all of the requested records that are in the Contractor's
8 possession or control, together with a written statement that the Contractor, after conducting a
9 diligent search, has produced all requested records that are in the Contractor's possession or
10 control, or(b) provide to the County a written statement that the Contractor, after conducting a
11 diligent search, does not possess or control any of the requested records. The Contractor shall
12 cooperate with the County with respect to any County demand for such records. If the
13 Contractor wishes to assert that any specific record or data is exempt from disclosure under the
14 CPRA or other applicable law, it must deliver the record or data to the County and assert the
15 exemption by citation to specific legal authority within the written statement that it provides to
16 the County under this section. The Contractor's assertion of any exemption from disclosure is
17 not binding on the County, but the County will give at least 10 days' advance written notice to
18 the Contractor before disclosing any record subject to the Contractor's assertion of exemption
19 from disclosure. The Contractor shall indemnify the County for any court-ordered award of costs
20 or attorney's fees under the CPRA that results from the Contractor's delay, claim of exemption,
21 failure to produce any such records, or failure to cooperate with the County with respect to any
22 County demand for any such records.
23 Article 12
24 Disclosure of Self-Dealing Transactions
25 12.1 Applicability. This Article 12 applies if the Contractor is operating as a corporation,
26 or changes its status to operate as a corporation.
27 12.2 Duty to Disclose. If any member of the Contractor's board of directors is party to a
28 self-dealing transaction, he or she shall disclose the transaction by completing and signing a
9
P-25-182
1 "Self-Dealing Transaction Disclosure Form" (Exhibit C to this Agreement)and submitting it to
2 the County before commencing the transaction or immediately after.
3 12.3 Definition."Self-dealing transaction" means a transaction to which the Contractor is
4 a party and in which one or more of its directors, as an individual, has a material financial
5 interest.
6 Article 13
7 General Terms
8 13.1 Modification. Except as provided in Article 6, "Termination and Suspension," this
9 Agreement may not be modified, and no waiver is effective, except by written agreement signed
10 by both parties, The Contractor acknowledges that County employees have no authority to
11 modify this Agreement except as expressly provided in this Agreement.
12 13.2 Non-Assignment. Neither party may assign its rights or delegate its obligations
13 under this Agreement without the prior written consent of the other party.
14 13.3 Governing Law.The laws of the State of California govern all matters arising from
15 or related to this Agreement.
16 13.4 Jurisdiction and Venue. This Agreement is signed and performed in Fresno
17 County, California. Contractor consents to California jurisdiction for actions arising from or
18 related to this Agreement, and, subject to the Government Claims Act, all such actions must be
19 brought and maintained in Fresno County.
20 13.5 Construction. The final form of this Agreement is the result of the parties' combined
21 efforts. If anything in this Agreement is found by a court of competent jurisdiction to be
22 ambiguous, that ambiguity shall not be resolved by construing the terms of this Agreement
23 against either party.
24 13.6 Days. Unless otherwise specified, "days" means calendar days.
25 13.7 Headings. The headings and section titles in this Agreement are for convenience
26 only and are not part of this Agreement.
27 13.8 Severability. If anything in this Agreement is found by a court of competent
28 jurisdiction to be unlawful or otherwise unenforceable, the balance of this Agreement remains in
10
P-25-182
1 effect, and the parties shall make best efforts to replace the unlawful or unenforceable part of
2 this Agreement with lawful and enforceable terms intended to accomplish the parties' original
3 intent.
4 13.9 Nondiscrimination. During the performance of this Agreement, the Contractor shall
5 not unlawfully discriminate against any employee or applicant for employment, or recipient of
6 services, because of race, religious creed, color, national origin, ancestry, physical disability,
7 mental disability, medical condition, genetic information, marital status, sex, gender, gender
8 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to
9 all applicable State of California and federal statutes and regulation.
10 13.10 No Waiver. Payment, waiver, or discharge by the County of any liability or obligation
11 of the Contractor under this Agreement on any one or more occasions is not a waiver of
12 performance of any continuing or other obligation of the Contractor and does not prohibit
13 enforcement by the County of any obligation on any other occasion.
14 13,11 Entire Agreement. This Agreement, including its exhibits, is the entire agreement
15 between the Contractor and the County with respect to the subject matter of this Agreement,
16 and it supersedes all previous negotiations, proposals, commitments, writings, advertisements,
17 publications, and understandings of any nature unless those things are expressly included in
18 this Agreement. If there is any inconsistency between the terms of this Agreement without its
19 exhibits and the terms of the exhibits, then the inconsistency will be resolved by giving
20 precedence first to the terms of this Agreement without its exhibits, and then to the terms of the
21 exhibits.
22 13.12 No Third-Party Beneficiaries. This Agreement does not and is not intended to
23 create any rights or obligations for any person or entity except for the parties.
24 13.13 Authorized Signature.The Contractor represents and warrants to the County that:
25 (A)The Contractor is duly authorized and empowered to sign and perform its
26 obligations under this Agreement.
27
28
11
P-25-182
1 (B) The individual signing this Agreement on behalf of the Contractor is duly
2 authorized to do so and his or her signature on this Agreement legally binds the
3 Contractor to the terms of this Agreement.
4 13.14 Electronic Signatures.The parties agree that this Agreement may be executed by
5 electronic signature as provided in this section.
6 (A)An "electronic signature" means any symbol or process intended by an individual
7 signing this Agreement to represent their signature, including but not limited to (1) a
8 digital signature; (2) a faxed version of an original handwritten signature; or(3)an
9 electronically scanned and transmitted (for example by PDF document)version of an
10 original handwritten signature.
11 (B) Each electronic signature affixed or attached to this Agreement(1)is deemed
12 equivalent to a valid original handwritten signature of the person signing this Agreement
13 for all purposes, including but not limited to evidentiary proof in any administrative or
14 judicial proceeding, and (2) has the same force and effect as the valid original
15 handwritten signature of that person.
16 (C)The provisions of this section satisfy the requirements of Civil Code section
17 1633.5, subdivision (b), in the Uniform Electronic Transaction Act(Civil Code, Division 3,
18 Part 2, Title 2.5, beginning with section 1633.1).
19 (D) Each party using a digital signature represents that it has undertaken and
20 satisfied the requirements of Government Code section 16.5, subdivision (a),
21 paragraphs (1)through (5), and agrees that each other party may rely upon that
22 representation.
23 (E) This Agreement is not conditioned upon the parties conducting the transactions
24 under it by electronic means and either party may sign this Agreement with an original
25 handwritten signature.
26 13.15 Counterparts. This Agreement may be signed in counterparts, each of which is an
27 original, and all of which together constitute this Agreement.
28 [SIGNATURE PAGE FOLLOWS]
12
P-25-182
1 The parties are signing this Agreement on the date stated in the introductory clause.
2
SHATANYA NUNN COUNTY OFFRESNO
3
Riley Digitally signed by Riley
Blackburn
4 J`J'�t� GVi'` Blackburn 15:30: 025A5A6
5:30:57-07'00'
5 Shatanya Nunn Riley Blackburn, Purchasing Manager
6 2218 N Fresno St.#101
Fresno, CA 93703
7
For accounting use only:
8
Org No.:56201715
9 Account No.:7295
Fund No.:0001
10 Subclass No.:10000
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
13
P-25-182
Exhibit A
Black Angel Mommies
Providing Healing space for Grieving Black Mothers experiencing Pregnancy and Infant Loss.
Facilitators Scope of Work
Scope of Work for Parent Facilitator(Shatanya Nunn)
Role Overview: The Parent Facilitator will primarily be responsible for supporting the emotional and
logistical needs of the support group sessions. This role involves preparing the meeting space,coordinating
session materials, and providing peer support to grieving parents.
1. Complete a 12-week virtual grief educator training program,which includes:
a.Viewing weekly recorded teachings.
b. Participating in weekly Zoom labs to review lessons and receive additional support.
2. Request and attend debriefing meetings with the Licensed Facilitator as needed duringthe training
period for additional support and guidance.
3. Collaborate with the MSW Facilitator and Licensed Facilitator by attending 1-2 monthly meetings,
each lasting one hour,to discuss and plan the bereavement group curriculum and activities.
4. Assist in preparing for the monthly grief support group meeting by:
a.Setting up the meeting room,including arranging chairs,tables, and any necessary equipment.
b.Assist with setting up snacks and refreshments for participants.
c. Preparing materials for session activities and crafts.
5. Attend and co-facilitate the monthly 1.5-hour Grief Support Group meeting.
6. Participate in a 30-minute debrief with the MSW Facilitator and Licensed Facilitator following each
Grief Support Group meeting to discuss outcomes, challenges,and improvements.
7. Maintain a welcoming, inclusive, and culturally sensitive environment for all participants.
8. Provide emotional support and share personal experiences to help guide and empower grieving
mothers.
9. Assist in monitoring the emotional well-being of participants and alert the Licensed Facilitator of
any concerns.
10. Collaborate with the MSW Facilitator and Licensed Facilitator to continually improve the program
based on participant feedback and facilitator observations.
11. Will be compensated at a rate of $30 per hour. for 4.5 hours each month. A total of$135 per
month.
P-25-182
Exhibit B
4 co
County of Fresno
"0' DEPARTMENT OF PUBLIC HEALTH
O�FRESCO David Luchini, Director
Dr. Rais Vohra, Interim Health Officer
AGREEMENT AND RELEASE OF LIABILITY
In consideration for being permitted to provide services as a facilitator on the land, facilities owned/occupied by
County of Fresno("County")located at various County locations and to engage in the bereavement support
group activities.
P TED NAME O CO
NT
R-ACTOR("RELEASER")
SIGNATURE OF CONTRACTOR("RELEASER") DATE
Hereby agree as follows:
INITIAL EACH OF THE FOLLOWING
1. C� �A I hereby RELEASE AND DISCHARGE the COUNTY from any and all liability, claims,demands,or
causes of action tht may hereafter have for injuries and damages arising out of my services in the bereavement support
group including but not limited to losses CAUSED BY THE NEGLIGENCE OF THE COUNTY.
2. �V 1 further agree that I will not sue or make claim against the COUNTY for damages or other losses
sustained as a result of my services in the bereavement support group activities.
r
3. J I also agree to INDEMNIFY AND HOLD THE COUNTY HARMLESS from all claims,
judgements and costs, including atorneys' fees incurred in connection with any action brought as a result of my
services in the bereavement support group activities.
4. l" I have been advised and recognize that my services in the bereavement support group
are not cowered by any personal accident or general liability insurance policy issued to the COUNTY.
5. J \ 1 hereby expressly recognize that this Agreement and Release of Liability is a contract pursuant to which I
have released any and all claims against the released Parties resulting from my services in the bereavement support
group activities including any claims caused by negligence of the COUNTY.
Promotion,preservation and protection of the community's health
1221 Fulton Street, Fresno,CA 93721 1 P.O. Box 11867, Fresno,CA 93721
(559)600-3200 1 FAX(559) 600-7687
The County of Fresno is an Equal Employment Opportunity Employer
www.fresnocountyca.gov I www.fcdr)h.org
P-25-182
Exhibit C
Self-Dealing Transaction Disclosure Form
In order to conduct business with the County of Fresno ("County"), members of a
contractor's board of directors ("County Contractor"), must disclose any self-dealing transactions
that they are a party to while providing goods, performing services, or both for the County. A
self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in
which one or more of its directors has a material financial interest."
The definition above will be used for purposes of completing this disclosure form.
Instructions
(1) Enter board member's name,job title (if applicable), and date this disclosure is being
made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that
the board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
The form must be signed by the board member that is involved in the self-dealing
transaction described in Sections (3) and (4).
C-1
P-25-182
Exhibit C
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a
party to)
(4) Explain why this self-dealing transaction is consistent with the requirements of
Corporations Code § 5233 (a)
(5)Authorized Signature
Signature: Date:
C-2