Business Name Phone (_____)___________ Email:

Address City State Zip Federal ID #

City of Oakland Business License Number Completed by: Phone if different

Schedule B-1 and C-1 (Declaration of Compliance with the Arizona Resolution 82727 and Declaration of Compliance with the Americans
with Disabilities Act)
I declare under penalty of perjury that my company is NOT headquartered in Arizona. OR
I declare under penalty of perjury that my company is headquartered in Arizona and my proposal/bid should be considered because

I declare under penalty of perjury that my company will comply with the City Of Oakland American with Disabilities Act obligations.
Schedule D (Ownership, Ethnicity and Gender) Please be advised that ethnicity and gender information will be used for reporting and tracking purposes ONLY.
Part I - Ownership & Ethnicity of Prime: (Please check one and explain below)
Self Employed, Name of Owner Corporation, State of Incorporation
Partnership, General or Limited Names of Partners
Joint Venture, Names of Participants
Ownership Interests
African American Indian/ Asian /Pacific Caucasian Filipino Hispanic Other
All owners must be listed Ethnicity American Alaskan Native Islander
in this information
Number of Owners
% Of Total Ownership
Women
Joint Venture
Ownership

Part II - Certifications DBE, MBE, SLEB, L/SLBE etc.: Please list certification type, certification number and expiration date. Please
attach a copy of the certification letter if available.

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 Part III - Ethnicity and Gender of Employees:

Male Female

Oakland Residents

Native American /

Native American /
African American

African American
Total Employees

Native Alaskan

Native Alaskan
Asian / Pacific

Asian / Pacific
Employment

Caucasian

Caucasian
Category

Hispanic

Hispanic
Islander

Islander
Other

Other
Project Management
Professional
Technical
Clerical
Trades

Schedule K (Pending Dispute Disclosure)

1. Are you or your firm involved in a pending dispute or claim Against the City of Oakland or its Agency? (Please circle one) Yes No

2. If Yes, please list existing and pending lawsuit(s) and claim(s) with the title, contract date, brief description of the issues, officials or staff
persons involved in the matter and the City department/division administering the contract. Contract Title and Number:
Date: Official(s), Staff person(s) involved: Administering Department/Division:
Issues: (check) ____ Additional Disputes listed on Attachment

Schedule M (Independent Contractor Questionnaire) PART A: TO BE COMPLETED BY PROPOSED CONTRACTOR

Please answer questions yes or no whenever possible. When a more extensive explanation is required and there is no space on this form,
please attach a separate sheet. The word contract refers to the agreement the City is contemplating entering into with you.
NOTE: CORPORATIONS MUST PROVIDE THE CORPORATE FEDERAL TAXPAYER NUMBER IN THE SPACE ABOVE AND ATTACH A
CALIFORNIA SECRETARY OF STATE BUSINESS REGISTRATION RECORD (FROM WEBSITE) SHOWING ACTIVE STATUS. CORPORATIONS
ARE NOT REQUIRED TO COMPLETE THE REMAINDER OF THIS FORM, BUT A CORPORATE REPRESENTATIVE MUST SIGN.

Yes No
1. Have you performed services for the City in any year(s) prior to 200__? If yes, please indicate which years.
2. Have you received any training, guidance, or direction from the City as to how the City expects the job (for which your services are
contemplated) to be done. If yes, please describe what you are expecting (or have received) in the way of training or direction.

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 Yes No
3. Will your services under the contract be performed on City property? If no, please describe where the services are to be performed.

4. Do you expect to devote any full days (6 or more hours) or full weeks (30 or more hours) towards performing the services under the
contract? If yes, please indicate approximately how many full days and/or full weeks you expect to devote during the life of the contract

5. Are there any set or fixed hours or days of the week during which the City is expecting you to perform services under the contract? If
yes, please indicate the days and hours during which you will be performing services.

6. Please provide the date on which you expect to complete your services under the contract (dd/mm/yy).
7. In order to perform services under the contract, do you intend to provide your own supplies or equipment? If yes, briefly describe the
equipment/supplies.

8. If your response to No. 7 is yes, has the City promised to or will you be expecting the City to reimburse you in any way for the cost of
the supplies or equipment?
9. Other than the above-referenced supplies and equipment, do you anticipate incurring any un-reimbursable out-of-pocket expenses in the
performance of the contract with the City? If yes, please describe.
10. Do you have federal and state employer identification numbers? If so, please provide these numbers.
11. Within the past two years have you performed the same type services (as called for in the contract) for any client or customer other than
the City? If yes, please identify the client or customer and briefly describe the services performed.

12. Do you currently have clients or customers other than the City for whom you are or will perform services during the duration of the
contract? If yes, please identify client or customer by name and briefly describe the nature of services performed.

13. In the past two years have you notified any insurance company in conjunction with obtaining a business-related insurance policy that
you are self-employed? If yes, please indicate the insurance company and the nature of the business-related policy.

14. Do you have your own employees to help you perform the services called for by your contract? (Do not refer to independent contractors
you may use to assist you.)
15. Within the past two years have you been the employee of any employer (received a W-2)? If yes, state the employer(s), the date(s) of
employment, and the nature of the services performed.
16. Do you have an office or business address other than your own home address, a City of Oakland office or your employers business
address? If yes, please state the address.
17. With regard to the following, please indicate whether you have:
a. an existing business letterhead? (please attach)
b. an existing business phone number other than your home number? (please indicate # along with area code)
c. filed for a fictitious business name? If yes, please attach a certified copy of the County issued certificate and an affidavit of
publication.
d. done public advertising for your business? If yes, please attach the ad copy or briefly describe your advertising efforts.
18. If you have answered parts or all of No. 17 with Yes, are the services represented in your answers the same type of services you will
be performing for the City?
19. Do you have a license from any governmental agency to perform the services under the contract? If yes, please state the type of license
and name of the licensing agency.

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 Yes No
20. Please describe the extent of any personal financial investment you have made in order to be self-employed. You may either choose to
indicate the actual dollar amount of investment or, without disclosing any dollar amount, briefly describe any purchases, leases or other
types of financial commitments made by you for self-employment purposes. _______________________________________

PLEASE INDICATE WHETHER YOU OBJECT IF THE CITY DECIDES TO TREAT YOU AS A SHORT-TIME CONTRACT EMPLOYEE RATHER
THAN AN INDEPENDENT CONTRACTOR AND THE REASON FOR YOUR OBJECTION.

FOR CITY USE ONLY

Based upon a review of this questionnaire and any other factors I have cited below, I have determined that this person (is) (is not) an independent contractor.

Date City Attorney/Assistant City Attorney/Deputy City Attorney

Schedule N - (Living Wage Declaration of Compliance) applicable to professional services contracts over $25K only

Employment Questionnaire: Please respond to the following questions:

Responses
(1) How many permanent employees are employed with your company? (If less than 5, stop here)
(2) How many of your permanent employees are paid above the Living Wage rate?

(3) How many of your permanent employees are paid below the Living Wage rate?

(4) Number of compensated days off per employee? (Refer to item a above)

(5) Number of trainees in your company?

(6) Number of employees under 21 years of age, employed by a nonprofit corporation for after school or summer
employment for a period not longer than 90 days.

Schedule N-1 (Equal Benefits Declaration of Nondiscrimination)

Section A. Contractor Information
(1) Are you an EBO certified firm (Please circle one) Yes No (if yes, please attached certificate and skip Schedule N-1)
(2) Approximate Number of Employees in the U.S. (3) Are any of your employees covered by a collective bargaining agreement or union
trust fund? (Please circle one) Yes No (4) Union name(s)

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 Section B. Compliance
(1) Does your company provide or offer access to any benefits to employees with spouses or to spouses of employees? (Please circle one) Yes No
(2) Does your company provide or offer access to any benefits to employees with domestic partners? (Please circle one) Yes No

Section C. Benefits PLEASE CHECK EACH BENEFIT THAT APPLIES

Benefits Offered to Offered to Offered to Employees Not Offered Documentation

Employees only Employees and their and their Domestic at all attached
spouses Partners
Health
Dental
Vision
Retirement (Pension, 401K, etc)
Bereavement
Family Leave
Parental Leave
Employee Assistance Program
Relocation & Travel
Company Discount, Facilities & Events
Credit Union
Child Care
Other

(1) CFAR is a City Financial Recipient. (2) Domestic Partner is defined a s a same sex couples or opposite sex couples registered as such with a state or
local government domestic partnership registry

Schedule P (Nuclear Free Zone - Ordinance 11474 C.M.S.)

I declare under penalty of perjury that I have read Ordinance 11478 C.M.S. titled An Ordinance Declaring the City of Oakland a Nuclear Free
Zone and Regulating Nuclear Weapons Work and City Contracts with and Investment in Nuclear Weapons Makers, as provided on the Citys
website, see footnote below I certify that my firm conforms with the conditions as defined in Ordinance 11478 C.M.S.

I declare that my company is NOT in compliance with Ordinance 11478 C.M.S., but my proposal/bid should be considered because

Schedule U (Compliance Commitment Agreement)

I have read the City of Oaklands Local/Small Local Business Enterprise Program (L/SLBE) and declare that I will achieve the 50%
L/SLBE participation requirement as described in the L/SLBE program including 50% of the total trucking dollars to
certified Oakland Local Truckers. If I fail to satisfy the proposed 50% L/SLBE participation requirement, I may be assessed a

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 penalty equal to 1 and times the shortfall. The 25% Small Local Business Enterprise (SLBE) subcontracting requirement is waived
for Oakland certified local businesses competing for professional services contracts as the prime consultant. The L/SLBE Program is
not applicable on Caltrans Federal Highway Administration (FHWA) funded DBE projects.

As prime contractor for this project, I agree to use the City of Oaklands Labor Compliance Program tracker (LCP Tracker) to input
ALL certified payroll reports including all tiers of subcontractors for this project. I acknowledge that invoice payments will not be
released until and unless all certified payrolls are current. I agree to submit with the final payment request a completed Exit Report
and Affidavit form located on the Citys website (see the link below).

Schedule V (Affidavit of Non-Disciplinary or Investigatory Action)

I certify that the following entities: Equal Employment Opportunity Commission (EEOC), Department of Fair Employment &
Housing (DFEH) or the Office of Federal Contract Compliance Programs (OFCCP) has not taken disciplinary or investigatory action
against the Firm. If such action has been taken, attached hereto is a detailed explanation of the reason for such action, the party
instituting such action and the status or outcome of such action. Initial:

Oaklands Minimum Wage Law (Resolution 85423 C.M.S. - Oakland Municipal Code Section 5.92, et seq.) I certify that I have read
Oaklands minimum wage law and I am in full compliance with all its provisions. Initial:

Affirmative Action - I certify that I/we shall not discriminate against any employee or applicant for employment because of race, color, creed, sex,
sexual orientation, national origin, age, disability, Acquired Immune Deficiency Syndrome (AIDS) AIDS related complex, or any other arbitrary
basis and shall insure compliance with all provisions of Executive Order No. 11246 (as amended by Executive Order No. 11375). I certify that I/we
shall not discriminate against any employee or applicant for employment because they are disabled veteran of the Viet Nam era and shall insure
compliance with all provisions of 41CFR60-250.4 where applicable. Initial:

By signing and submitting this combined schedules form the prospective primary participants authorized representative
hereby obligates the proposer(s) to the stated conditions referenced in this document. I declare under penalty of perjury that
the foregoing is true and correct.

Name of Individual: Title:

Signature: Date:

PLEASE NOTE: Detailed descriptions of all policies represented in this combined form may be found at Contracts and Compliance website Policies and
Legislation address http://www2.oaklandnet.com/Government/o/CityAdministration/d/CP/s/policies/index.htm For an electronic copy of this combined
form and copies of standalone contract Schedules R, E, O, Q, Exit Affidavit and Schedule G please go to this web address
http://www2.oaklandnet.com/Government/o/CityAdministration/d/CP/s/FormsSchedules/index.htm

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