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.............. ' ~ ,~,'~ ~ ~ ~ ~ ~ ~ ~ I v~- ~'~w I s~-~ 16505963~8 P. 01/01 <br /> ' ~ - COUNTY OF SAN MATEO <br /> <br /> Equal Benefi Compliance Declaration Form <br /> <br /> .i vendor Identification <br /> <br /> Contact Person: ~ ~ t~ - / . <br /> Address: [e~ ? ~,~d/~C~ ~'. <br /> <br /> Phone N0mbe~ ~_ ~0 ~ ~ ~[. <br /> . Fax Number: <br /> <br /> II Employee~' " ~~-~ <br /> Does the Conmct0r have any employees* [~ Yes ~ No ' <br /> <br /> Doo~ th~ Gon~a~tor provide b,nefi~ to gpou~ of,mploy~ , ~ No <br /> <br /> ~f ~ answer to one or both of ~e above i~ n0, please sMp'to Se~on IV.' <br /> <br /> I11 Equal Benefi~ Compliance (Check one) ' ' <br /> <br /> ~ Ye~, the Contra~or complies by offering equal benefit, as defined by Chapte~ 2.93, to <br /> ' employees with spouses and ~s employees ~th domestic pa~ners, . <br /> y ~ Yes, ~e.Con~or complies by offe~ng a cash equivalent payment to ~ligible employees <br /> ~ in lieu of equal benefits, · '. ' <br />~j ~ ~ N~he Contractor does not corn?. . , , · ' ' <br />~ ~v~ ~e Conffa~or is under a collec~ve bargaining agreement ~ich b~an on 0~ <br />~ (date) and e~ires on~ I,~=~date). ' · · <br /> <br /> IV Declaration .. <br /> I declare unde~ penal~ of perju~ undet ~e laws of the S~te of ~lifomia t~at <br /> ~e and ~e~, and that I am auto,zed to.bindthis en~ ~n~a~ually, . . ~..~. ~ <br /> <br /> . . · , ..,. -/ .-.. , <br /> Signature .- ' · ' / Name (Pl~asEPrint) " <br /> <br /> TMe .I ' ~. '. Contractor Tax IdentBcafion Number <br /> <br /> <br />