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COUNTY OFSAN MATEO' '~,/r'/~' <br /> Equal 'Benefits Compliance Declaration Form <br /> <br />I Vendor Identification <br /> <br /> Name of Con~'ac~or: <br /> <br /> Contact Person: <br /> <br /> Address: <br /> <br /> Phone Number: Fax Number: <br /> <br />II Employees <br />Does the Cont, actor- have any employees?Vyes No <br />Does the Contractor provide benefits to spouse-" of employees? V' Yes No · <br /> <br />Ill Equal Banefi~ Complianc~ (Check cna) <br /> <br /> ~ Yes- the Contractor complies by <br /> em;Ioyees with spouses and iS ~ployees with domestic paKnem. <br /> ~ Yes. the Contractor ~mplies by offering a cash equivalent.payment to eligible employees <br /> t of ~qual beneS. <br /> he Contractor d~s not comply. . <br /> on~a~r is under a colle~i~'~argaining agreement which began on <br /> <br /> IV Declaration <br /> <br /> I declare under penalty of perjury Under the laws off. he State of California that'the foregoing is. <br /> true and correct, and ~at lam.authorized to bind this entity.contractually. <br /> . ... :, . <br /> _.._..ut_d th~. , . day of' , .. <br /> : (City) J (State) <br /> <br /> S,;.~.-re -:'" Name (Please Print) <br /> <br /> ~itie ' Contractor Tax Identification Number <br /> <br /> <br />