5-Bidder Contribution CEC Form 55.pdf

FORM Prohibited Contributors

(Bidders)

Revised February 2022 Los Angeles City Charter § 470(c)(12), Los Angeles Municipal Code §§ 49.7.35(B)(3), (4) Page 1 of 3 ethics.lacity.org

This form must be completed in its entirety and submitted with your bid or proposal to the City department that is awarding the contract. Failure to submit a completed form may affect your bid or proposal. If you have questions about this form, please contact the Ethics Commission at (213) 978-1960.

Original Filing Amendment: Date of Signed Original ________________. Date of Last Amendment _________________.

Schedule Summary

Please complete all three of the following:

1. SCHEDULE A — Bidder’s Principals (check one) The bidder has one or more PRINCIPALS, as defined in LAMC § 49.7.35(A)(6).

At least one principal is required for entities. (If you check “Yes”, Schedule A is required.)

2. SCHEDULE B — Subcontractors and Their Principals (check one) The bidder has one or more SUBCONTRACTORS on this bid or proposal with subcontracts worth $100,000 or more. (If you check “Yes”, Schedule B is required.)

3. TOTAL NUMBER OF PAGES SUBMITTED (including this cover page): _______

Yes No

Yes No

Certification

Name Signature

Title Date

I certify the following under penalty of perjury under the laws of the City of Los Angeles and the state of California:

A) I understand, will comply with, and have notified my principals and subcontractors of the requirements and restrictions in Los Angeles City Charter § 470(c)(12) and any related ordinances; B) I understand that I must amend this form within ten business days if any information changes; C) I am the bidder named above or I am authorized to represent the bidder named above, and my name appears below; and D) The information provided in this form is true and complete to the best of my knowledge and belief.

Reference Number (Bid, Contract, or RAMP): ___________________________ Date Bid Submitted: ____________________

Contract Description (Title of the RFP or City contract solicitation and description of the services to be provided):

Awarding Authority (Department awarding the contract): ________________________________________________________

Bidder Name: ____________________________________________________________________________________________________

Bidder Address: _________________________________________________________________________________________________

Bidder Email Address: __________________________________________ Bidder Phone Number: ________________________ https://codelibrary.amlegal.com/codes/los_angeles/latest/laac/0-0-0-1874 https://codelibrary.amlegal.com/codes/los_angeles/latest/lamc/0-0-0-224321 https://ethics.lacity.org

(Bidders)

Revised February 2022 Los Angeles City Charter § 470(c)(12), Los Angeles Municipal Code §§ 49.7.35(B)(3), (4) Page 2 of 3 ethics.lacity.org

Please identify the names and titles of all the bidder’s principals (attach additional sheets if necessary). Principals include a bidder’s board chair, president, chief executive officer, chief operating officer, and individuals who serve in the functional equivalent of one or more of those positions. Principals also include individuals who hold an ownership interest in the bidder of at least 20 percent and employees of the bidder who are authorized by the bid or proposal to represent the bidder before the City.

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Schedule A - Bidder’s Principals

Check this box if additional Schedule A pages are attached.

https://codelibrary.amlegal.com/codes/los_angeles/latest/laac/0-0-0-1874 https://codelibrary.amlegal.com/codes/los_angeles/latest/lamc/0-0-0-224321 https://ethics.lacity.org

(Bidders)

Revised February 2022 Los Angeles City Charter § 470(c)(12), Los Angeles Municipal Code §§ 49.7.35(B)(3), (4) Page 3 of 3 ethics.lacity.org

Please identify all subcontractors whose subcontracts are worth $100,000 or more. Separate Schedule B pages are required for each subcontractor who meets the threshold.

Schedule B - Subcontractors and Their Principals

Subcontractor’s Name

Subcontractor’s Address

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Name: _______________________________________________________________ Title: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

Please check one of the following options:

This subcontractor has one or more principals. Yes* No

Each principal’s name and title must be identified below. Attach additional sheets if necessary. Principals include a subcontractor’s board chair, president, chief executive officer, chief operating officer, and individuals who serve in the functional equivalent of one or more of those positions. Principals also include individuals who hold an ownership interest in the subcontractor of at least 20 percent and employees of the subcontractor who are authorized by the bid or proposal to represent the subcontractor before the City.

Check this box if additional Schedule B pages are attached.

https://codelibrary.amlegal.com/codes/los_angeles/latest/laac/0-0-0-1874 https://codelibrary.amlegal.com/codes/los_angeles/latest/lamc/0-0-0-224321 https://ethics.lacity.org