2026-605_Workforce_and_Equal_Pay_Declaration_Form.pdf
PDF 178 KB Posted
- Solicitation number
- 2000017921
- Issued by
- Washington County, Minnesota
About this file
This document is a Prime Contractor Response Form for Workforce and Equal Pay Declaration required by the Minnesota Department of Human Rights for businesses executing government contracts with state, local, and university entities.
The form requires contractors to declare their certification status regarding Workforce and Equal Pay Certificates. Contractors must select one of four options: confirm they hold current certificates under specified names, indicate they are applying or have applied for certificates with application dates, acknowledge they have not applied and understand certification is required before contract execution, or claim exemption by attesting they have not employed 40 or more employees on a single day during the prior 12 months in Minnesota or their primary state of business. The form applies to businesses executing contracts with State or Metropolitan agencies exceeding $100,000 (Workforce Certificate) and $500,000 (Equal Pay Certificate); University of Minnesota general obligation bond funded capital projects exceeding $100,000 and $500,000 respectively; or Political Subdivisions general obligation bond funded capital projects exceeding $250,000 and $1,000,000 respectively.
Contractors must complete Part 2 by providing vendor/supplier identification, business name, contracting agency name, authorized signatory information including name, title, date, signature, email, and phone number. The Minnesota Department of Human Rights reserves the right to request employee records from the prior 12 months, including names, separation dates, and current employment status to verify compliance. Assistance with form completion is available through the Minnesota Department of Human Rights at Compliance.MDHR@state.mn.us.
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Text version
PRIME CONTRACTOR RESPONSE FORM
Workforce and Equal Pay Declaration Page
This form is required for all businesses executing government contracts under the following:
PART 1 - SELECT ALL THAT APPLY:
1.01 WE ARE A CERTIFICATE HOLDER:
☐ Workforce Certificate under the name:
☐ Equal Pay Certificate under the name:
1.02 WE ARE APPLYING/HAVE APPLIED FOR THE FOLLOWING CERTIFICATE(S):
☐ Workforce Certificate Application date (MM/DD/YYYY):
☐ Equal Pay Certificate Application date (MM/DD/YYYY):
1.03 WE HAVE NOT APPLIED FOR ONE OR BOTH CERTIFICATES:
☐ Our company does not yet have a Workforce Certificate or Equal Pay Certificate. We acknowledge that a
Workforce Certificate and, if applicable, Equal Pay Certificate, or approved exemption by the Minnesota Department of Human Rights is required before a contract can be executed.
1.04 WE ARE EXEMPT:
☐ We attest to the Minnesota Department of Human Rights that we have not employed 40 or more employees on a single day during the prior 12 months in Minnesota or the state in where we have our primary place of business. The Minnesota Department of Human Rights may request the names of our employees during the previous 12 months, the date of separation, if applicable, and the current employment status and count.
PART 2 - BUSINESS INFORMATION
Vendor/Supplier ID Business Name Name of Contracting Agency
Authorized Signatory Name Title Date
Signature Email Phone
For assistance with this form, email the Minnesota Department of Human Rights Compliance.MDHR@state.mn.us
Select one:
☐ Businesses executing a contract with State or Metropolitan agencies in excess of $100,000 (Workforce Certificate) and, if applicable, $500,000 (Equal Pay Certificate)
☐ Businesses executing a contract with University of Minnesota for general obligation bond funded capital projects in excess of $100,000 (Workforce Certificate) and, if applicable, $500,000 (Equal Pay Certificate)
☐ Businesses executing a contract with Political Subdivisions for general obligation bond funded capital projects in excess of $250,000 (Workforce Certificate) and, if applicable, $1,000,000 (Equal Pay mailto:Compliance.MDHR@state.mn.us https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/equalpay/
| PART 1 - Select all that apply: |
| 1.01 We are a certificate holder: |
| 1.02 We are applying/have applied for the following certificate(s): |
| 1.03 We have not applied for one or both certificates: |
| 1.04 We are Exempt: |
PART 2 - Business Information
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