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Equal Benefits Compliance Declaration Form <br /> <br /> I Vendor Identification <br /> Name of Contractor. <br /> Contact Parson: <br /> Address: <br /> <br /> Phone Number. Fax Number. <br /> <br /> II Employees <br /> <br /> Does the Contractor have any emploYees? [] Yes [] No <br /> Does the Contractor provide benefits to spouses of employees? [] Yes [] No <br /> *If the answer to one or both of the above is no, please skip to Section IV.* <br /> <br /> III Equal Benefits Compliance (Check one) <br /> [] 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 /> [] Yes, the Contractor complies by offering a cash equivalent payment to eligible employees <br />' in lieu of equal benefits. <br /> [] No, the Contractor does not comply. <br /> [] The Contractor is under a COllective bargaining agreement which began on or before <br /> JulY 1, 2001 and exp!res on . (Section 2.93.050) <br /> (date), <br /> <br /> IV Declaration <br /> I declare under penalty of penury under the laws of the State of California that the foregoing is <br /> true and COrrect, and that I am' authorized to bind this entity COntractually. <br /> <br /> Executed this . day of , at ., <br /> (City) (State) <br /> <br /> Signature Name (Please Print) <br /> <br /> Title Contractor Tax Identification Number <br /> <br /> <br />