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<br />, <br />... ;:.. <br />. <br /> <br />Exhibit D <br /> <br />COUNTY OF SAN MATEO <br /> <br />Equal Benefits Compliance Declaration Form <br /> <br />I Vendorldentlficatlon <br /> <br />Phone Number: <br />Fax Number: <br /> <br /> <br />Name of Contractor: <br />Contact Person: <br />Address: <br /> <br />n Employees <br />Does the Contractor have any employees? ~ Yes 0 No <br />Does the Contractor provide benefits to spouses of employees? ~ es 0 No <br /> <br />*Ifthe answer to one or both of the above is no, please skip to Section IV. * <br /> <br />ill Eqr1 Benefits Compliance (Check oqe) <br /> <br />IYf 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 />DYes, the Contractor complies by offering a cash equivalent payment to eligible employees <br />in lieu of equal benefits. <br />o No, the Contractor does not comply. <br />o The Contractor is under a collective bargaining agreement which began on <br />( date) and expires on ( date) <br /> <br />IV Declaration <br /> <br />I declare under penalty of perjury under the laws of the State of California that the foregoing is true and <br />correct, t ~a t rizoo to bind this entity cUtract&~df <br /> <br /> <br />Signature I Name (Please Print) <br /> <br />U ~ IY\tU'\ilN/ 1- 2 5 -o(p <br />Title U Date <br /> <br />