Laserfiche WebLink
<br />Rug 25 04 04:15p <br /> <br />JRWC Park Reo <br />-' ,. " -, <br /> <br />650 368 5087 <br /> <br />p.3 <br /> <br />, . <br /> <br />COUNTY OF SAN MATEO <br />Equal Benefits Compliance Declaration Form <br /> <br />I v.endor Identification <br />Name of Contractor: <br /> <br />Contact Person: <br />Address: <br /> <br />Phone Number. '¡ <br />.-" " <br /> <br /> <br />II Employees <br />'Does the èontractor have any ~mployees? ~ Yes 0 No <br />Does the Contra~C?r provide brmefits to spouses ~f e~pIOyeeS?' ~ Yes 0 No <br /> <br />-If the answerto ane or both of the above is no, please skip to Section IV,- <br /> <br />In Equal Benefits Comptiance (Chet:k one) <br /> <br />0 Yes. the Contractor complies by offering equal benefits,as defined by Chapter 2.93. to its <br />employees with spouses and its employees with domestic partners. <br />0 Yes, the Contractor complies by offering a cash equivalent payment to eligib1e employees <br />......I. in lieu of equal benefits. . <br />OCI No. the Contractor does not comply. <br />0 The Contractor is under a collective bargaining agreement which began on or before <br />Ju!y 1, 2001 and expires on (date). (Section 2.93.050) <br />If this box .i~ checked. attach a complete copy of the collective bargaining <br />agreement.".~~;Ued up:m "r this exemption. <br /> <br />I declare under petlalty of perjury under the laws of the State of California that the foregoing is <br />true and correct. a~tha! I am ~~ Ie bin~ ~~A'"tily ~:l.. ctuallr. rrh A (() A <br />cutad !hi day of f--\ \Â , ~at~J4!!'i u< <br />, '. (City) (State) <br />AVêJ.ccLt hëv(õ <br />Name (Please Print) <br />qA~loOD l \ lo <br /> <br />Contractor Tax Identification Number <br /> <br />IV Declaration <br /> <br /> <br />\, <br />Signature <br /> <br />~ 6V\U~ ãtt- Aw1 IA&+ <br />. Title ' <br /> <br />... ..........."'" <br />. """"""""'-"""""'---""""'--""""'" <br />