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Exhibit D County of San Mateo Contractor's Declaration Form L CONTRACTOR INFORMATION Contractor Name: Contact Person: Address: II. EQUAL BENEFITS (check one or more boxes) Contractors with contracts in excess of$5,000 must treat spouses and domestic partners equally as to employee benefits. K Contractor complies with the County's Equal Benefits Ordinance by: K offering equal benefits to employees with spouses and employees with domestic partners. r offering a cash equivalent payment to eligible employees in lieu of equal benefits. Contractor does not comply with the County's Equal Benefits Ordinance. Contractor is exempt from this requirement because: Contractor has no employees, does not provide benefits to employees' spouses, or the contract is for $5,000 or less. r r r r Cqntractor is a party to a collective bargaining agreement that began on _ (date) and expires on_ (date), and intends to offer equal benefits when said agreement expires. III. NON~DISCRIMINA TION (check appropriate box) Finding(s) of discrimination have been issued against Contractor within the past year by the Equal r Employment Opportunity Commission, Fair Employment and Housing Commission, or other investigative entity. Please see attached sheet of paper explaining the outcome( s) or remedy for the discrimination. K No fmding of discrimination has been issued in the past year against the Contractor by the Equal ' Employment Opportunity Commission, Fair Employment and Housing Commission, or any other entity. IV. EMPLOYEE JURY SERVICE (check one or more boxes) Contractors with original or amended contracts in excess of $ 100,000 must have and adhere to a written policy that provides its employees living in San Mateo County up to five days regular pay for actual jury service in the County. ~ r r Contractor complies with the County's Employee Jury Service Ordinance. Contractor does not comply with the County's Employee Jury Service Ordinance. Contractor is exempt from this requirement because: ,r the contract is for $100,000 or less. Contractor is a party to a collective bargaining agreement that began on _ (date) and expires on _ (date), and intends to comply when the collective bargaining agreement expires. r I declare under penalty of peljury under the laws of the State of California that the foregoing is true and correct, and that, i~ auth ized.l6 bind)thise~t,ity ontractually. ," 17, ' J ';- r "', / ,,' /i t BeYr!r2 ~ 12 e71~L e Y )rh (\fs,t/",,' 'Signature II', '\~- ",' Name ' . . "lil Q'. /J ,'~ D ~z:'" c/ ~-, it.{(."-,, Date Title 19