FORM6-~8.PDF

Form 6 Please use this Form for Solicitation B2727161

Mandatory Campaign Contribution Disclosure Form

This fillable PDF must be used to complete your financial disclosures. If you require additional space to list all of your contributions, please provide an excel spreadsheet in the same format as Exhibit 1 attached.

Once you select if you are a "business" or "individual" the appropriate questions will appear. Please answer as completely as possible. Once you complete the question on each page, select "Continue" to go to the next page. You must have Adobe to be able complete this form. If you do not have Adobe, you can download it by going here: https://get.adobe.com/reader/." If you need to complete the form as a business and as an individual, please complete and submit two separate forms.

Contribution Disclosure Information

*Required fields

*Is the Applicant an individual or business? Individual Business

* Vendor:

* Date:

* RFP/Bid:

Consultant Disclosure Information

*Required Fields:

Check here to certify if a consultant(s) was used in the year prior to the application deadline for this contract opportunity. (Click 'Continue’ if this does not apply)

List all consultant(s) used in the year prior to the application deadline for this contract opportunity. Please be sure to refer to the definition of Consultant before completing this form.

Vendor Disclosure Information

*Required Fields:

List all consultant(s) used in the year prior to the application deadline for this contract opportunity. Please be sure to refer to the definition of Consultant before completing this form.

Vendor City Employee Request Disclosure

*Required Fields

Check here if one or more City employees or officers 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) during the two years prior to the application deadline for this contract opportunity. (Click "Continue" if this does not apply.)

Vendor City Employees Participation Advice Disclosure

*Required Fields

Check here if one or more City 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.

Vendor Signature on Application

In order for an application to be considered valid, it must be properly signed by the applicant. The Application may not be signed by anyone other than the Applicant or an authorized officer or employee of the Applicant. Applications that are not signed will be rejected. By typing your name and title in the signature space below, you, as the applicant, signify your intent to sign this application. Someone other than the proper signatory may not type in another’s signature. All signatories hereby declare and certify that they are the Applicant or are employees or officers of the Applicant duly authorized to execute this Application and make disclosures on the Applicant’s behalf; and represent and covenant that, to the best of their knowledge after appropriate inquiry, all of the information and disclosures provided are true and contain no material misstatement or omissions.

If application is being submitted by an INDIVIDUAL, SOLE PROPRIETOR, PARTNERSHIP, LIMITED LIABILITY PARTNERSHIP, LIMITED LIABILITY COMPANY, or any other legally formed entity except a corporation (see below) sign the application here, with a signature by either the Individual, Owner, Partner, Member or Manager. If the application is not signed by the above mentioned, by signing in the Authorized Signatory box provided below, you hereby certify that you are authorized to sign in place of such officers:

If application is being submitted by a CORPORATION, sign the application 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 application is not signed by the above mentioned, you herby certify that you are authorized pursuant to a certified corporate resolution to sign in place of such officers.

Signature of Individual/Owner/Partner/Member/Manager

Authorized Signatory

President/Vice President

Secretary/Asst. Secretary/Treasurer/Assistant Treasurer

Authorized Signatory

Exhibit 1.

Mandatory Political Disclosure Template

Mandatory Political Disclosure Template Respondent:

Solicitation No.:

Number Contributor Name Relationship to Applicant/Vendor Recipient Name Contribution Date Amount

of a for‐profit affiliate of the Applicant, made any contributions?

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 contribution, although only the amount above $3,000 will be attributed to the office, director, controlling shareholder, or partner (and, by extension, the applicant business).

Value Requested:

lblValueRequested7-2: Money Service of Thing of Value Requested:

lblValueGiven7: Money, Service or Thing of Value Given:

(if none, write 'none') lblValueGiven7-2: Money, Service or Thing of Value Given:

(if none, write 'none')

Value Requested:

Value Requested:

lblValueGiven7-3: Money, Service or Thing of Value Given:

(if none, write 'none') lblValueGiven7-4: Money, Service or Thing of Value Given:

(if none, write 'none')

participation goals:

lblParticipationGoals8-2: Individual or Business Recommended to satisfy participation goals:

participation goals:

lblParticipationGoals8-4: Individual or Business Recommended to satisfy participation goals: