To be completed by City Representative prior to distribution to Contractor
City Representative ________________________________________ Phone ___________________________ Project Spec No. ______________
Department ________________________________ Contract/Proposal Name _________________________________________________________
Contractor Name __________________________________________________________________
Phone ________-________-________
Street Address ______________________________________________
City ________________, State _______ Zip __________
Type of Submission (check one) ______ Bid ______Proposal ______ Qualification ______ Amendment
Individual or Business Name ________________________________________________
Phone ________-________-________
Street Address ______________________________________________
City ________________, State _______ Zip __________
The undersigned Contractor's Representative acknowledges by his or her signature the following:
_______/________/________
Print Name of Signer Position
To be Completed by City of Oakland after completion of the form
Date Received by City: _______/________/________ By ___________________________________________________
Date Entered on Contractor Database: _______/_______/_______ By ____________________________________________________
CONTRACTOR ACKNOWLEDGEMENT OF CITY OF OAKLAND CAMPAIGN CONTRIBUTION LIMITS
I have read Oakland Municipal Code Chapter 3.12, including section 3.12.140, the contractor provisions of the Oakland
Campaign Reform Act and certify that I/we have not knowingly, nor will I /we make contributions during the period
specified in the Act.
I understand that the contribution restrictions also apply to entities/persons affiliated with the contractor as indicated in the
Oakland Municipal Code Chapter 3.12.080.
If there are any changes to the information on this form during the contribution-restricted time period, I will file an
amended form with the City of Oakland.
This is an ______ Original ______ Revised form (check one). If Original, complete all that applies. If Revised, complete Contractor
name and any changed data.
Majority Owner (if any). A majority owner is a person or entity who owns more than 50% of the contracting firm or entity.
The Oakland Campaign Reform Act limits campaign contributions and prohibits contributions from contractors doing
business with the City of Oakland and the Oakland Redevelopment Agency during specified time periods. Violators are
subject to civil and criminal penalties.
FOR CONSTRUCTION, PROFESSIONAL SERVICE & PROCUREMENT CONTRACTS
