Agmt10 County of San Mateo (2) - Laserfiche WebLink

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Exhibit C County of San Mateo Contractor's Declaration Form I. CONTRACTOR INFORMATION Contractor Name: Contact Person: Address: F air Oaks Phone: Fax: 650 780-7500 650 298-8184 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. it Contractor complies with the County's Equal Benefits Ordinance by: ~ offering equal benefits to employees with spouses and employees with domestic partners. Ci offering a cash equivalent payment to eligible employees in lieu of equal benefits. o Contractor does not comply with the County's Equal Benefits Ordinance. e 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 D or less. Contractor is a party to a collective bargaining agreement that began on _ (date) and expires on _ D (date), and intends to offer equal benefits when said agreement expires. III. NON-DISCRIMINATION (check appropriate box) Finding(s) of discrimination have been issued against Contractor within the past year by the Equal Employment D 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 d,iscrimination. r:/ No finding 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 p~ov~es its employees living in San Mateo County up to five days regular pay for actual jury service in the County. !!( Contractor complies with the County's Employee Jury Service Ordinance. g/ Contractor does not comply with the County's Employee Jury Service Ordinance. ~ COJ)tractor is exempt from this requirement because: ~ the contract is for $1 00,000 or less. e c(dontr)actodr i~ a Pdarty to a cO,lIecthive bahrgainlling .agrbeeme~t. that began on --:- (date) and expires on_ ate, an mten s to comp y w en t e co ectlve argalnlng agreement expires. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually. Signature ~_/ ',-, b- r ~ -{ D l.e--\- vr: -:1V\t't r-l0VV\.- Name ,J cJvl V~~{;'J;V'-5 -e .( Title Date 8-7-06 Page 1 of 1 J