AGENCY CODE

TELEPHONE NUMBER (Include area code)CONTRACTOR'S NAME

ADDRESS CITY STATE ZIP CODE

FEDERAL EMPLOYER I.D. NUMBER NAME OF CONTRACTOR'S AGENT WHO SIGNED THE CONTRACT

CONTRACT INFORMATION STATE CONTRACT NUMBERCONTRACT AMOUNT CONTRACT AWARD DATE

PROJECT LOCATION (County) COUNTY CODE

TYPE OF CONTRACT

Construction IT Service Non-IT ServicesIS THIS PROJECT FEDERALLY FUNDED?

YES NO

AWARDING AGENCY INFORMATION

TELEPHONE NUMBER (Include area code)

AGENCY NAME

AGENCY ADDRESS CITY STATE ZIP CODE

NAME OF CONTRACT AWARDING OFFICER

CONTRACTOR INFORMATION SHADED AREAS FOR OFFICE OF COMPLIANCE PROGRAMS USE ONLY

STD 16 (Rev. 6/2017) CONTRACT AWARD REPORT STATE OF CALIFORNIA

MONTH DAY YEARESTIMATED PROJECT STARTING DATE:

ESTIMATED PROJECT COMPLETION DATE:

YEARDAYMONTH

Title 2, Division 4.1, Chapter 5, Section 11114 of the California Code of Regulations requires contract awarding agencies to notify the Department of Fair Employment and Housing, Office of Compliance Programs, of any contract award in excess of $5,000. Submit one completed copy of this form to the Office of Compliance Programs for each contract in excess of $5,000 within 10 days of award date. Forms may be submitted to: CompliancePrograms@dfeh.ca.gov.

IT Goods Non-IT Goods