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6.D. - Page 117 of 170 CITY OF LOS ANGELES - SLAVERY DISCLOSURE ORDINANCE Unless otherwise exempt from the Slavery Disclosure Ordinance (SDO), a Company entering into a Contract with the City must complete an Affidavit disclosing any and all records of Participation or Investment in, or Profits derived from Slavery, including Slaveholder Insurance Policies, during the Slavery Era. The Company must complete and submit the Affidavit and any attachments on LABAVN ( www.labavn.org) before a Contract or Contract Amendment can be executed. The Affidavit must only be submitted once on LABAVN, but contractors are responsible for updating their Affidavit if changes occur to any information contained therein. Questions regarding the Affidavit may be directed to the Department of Public Works, Bureau of Contract Administration, Office of Contract Compliance. Website: http://bca.lacity.org/index.cfm; Phone: (213) 847-2625; E-mail: bca.eeoeo_lacity.org. AFFIDAVIT DISCLOSING SLAVERY ERA PARTICIPATION, INVESTMENTS, OR PROFITS 1. I, 01+W_t 5 E, KAUFAAN , am authorized to bind contractually the Company identified below. 2. Information about the Company entering into a Contract with the City is as follows: __JH 15 Pu NJ& 86STF OMaomPANI M-M-Aao y?-/dg%9/ Company Name Phone Federal ID # grips BAVN company � g9 ya Street Address City State Zip 3. The Company came into existence in 0? 00 a (year). 4. The Company has searched its records and those of any Predecessor Companies for information relating to Participation or Investments in, or Profits derived from, Slavery or Slaveholder Insurance Policies. Based on that research, the Company represents that (mark only the option(s) that apply): The Company found no records that the Company or any of its Predecessor Companies had any Participation or Investments in, or derived Profits from, Slavery or Slaveholder Insurance Policies during the Slavery Era. The Company found records that the Company or its Predecessor Companies Participated or Invested in, or derived Profits from Slavery during the Slavery Era. The nature of that Participation, Investment, or Profit is described on the attachment to this Affidavit and incorporated herein. The Company found records that the Company or its Predecessor Companies bought, sold, or derived Profits from Slaveholder Insurance Policies during the Slavery Era. The names of any Enslaved Persons or Slaveholders under the Policies are listed on the attachment to this Affidavit and incorporated herein. 5. 1 declare under penalty of perjury under the laws of the State of California that the representations made herein are true and correct to the best of my knowledge. \ / Executed on iA a0 'A Z. at ate) (City) (State) Signature: Title: PR E51 lb 6N DEFINITIONS Affidavit means the form developed by the DAA and may be updated from time to time. The Affidavit need not be notarized but must be signed under penalty of perjury. Company means any person, firm, corporation, partnership or combination of these. Contract means any agreement, franchise, lease or concession including an agreement for any occasional professional or technical personal services, the performance of any work or service, the provision of any materials or supplies or rendering of any service to the City of Los Angeles or the public, which is let, awarded or entered into with or on behalf of the City of Los Angeles or any Awarding Authority of the City. Enslaved Person means any person who was wholly subject to the will of another and whose person and services were wholly under the control of another and who was in a state of enforced compulsory service to another during the Slavery Era. Investment means to make use of an Enslaved Person for future benefits or advantages. Participation means having been a Slaveholder during the Slavery Era. Predecessor Company means an entity whose ownership, title and interest, including all rights, benefits, duties and liabilities were acquired in an uninterrupted chain of succession by the Company. Profits means any economic advantage or financial benefit derived from the use of Enslaved Persons. Slavery means the practice of owning Enslaved Persons. Slavery Era means that period of time in the United States of America prior to 1865. Slaveholder means holders of Enslaved Persons, owners of business enterprises using Enslaved Persons, owners of vessels carrying Enslaved Persons or other means of transporting Enslaved Persons, merchants or financiers dealing in the purchase, sale or financing of the business of Enslaved Persons. Slaveholder Insurance Policies means policies issued to or for the benefit of Slaveholders to insure them against the death of, or injury to, Enslaved Persons. OCC/SDO-1 Affidavit (Rev. 12/14) 200