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<br /> 5.1H <br /> Page 19 <br /> Exhibit D <br /> COUNTY OF SAN MATEO <br /> Equal Benefits Compliance Declaration Form <br /> I Vendor Identification <br /> Name of Contractor: <br /> Contact Person: <br /> Address: <br /> Phone Number: <br /> Fax Number: <br /> II Employees <br /> Does the Contractor have any employees? 0 Yes 0 No <br /> Does the Contractor provide benefits to spouses of employees? DYes ONo <br /> *Ifthe answer to one or both of the above is no, please skip to Section IV. * <br /> III Equal Benefits Compliance (Check one) <br /> o 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 /> IV Declaration <br /> I declare under penalty of perjury under the laws of the State of California that the foregoing is true and <br /> correct, and that I am authorized to bind this entity contractually. <br /> Signature Name (Please Print) <br /> Title Date <br /> -~". <br />