Attachment_D.pdf
PDF 215 KB Posted
- Attached to
- MNIT/AELSBOA RFP ITN Licensure Compliance System
- Solicitation number
- 2000018382
- Issued by
- Ramsey County, Minnesota
About this file
This is a Workforce and Equal Pay Declaration form required by the Minnesota Department of Human Rights (MDHR) for businesses executing government contracts with state, metropolitan, university, or political subdivision agencies. The form applies to contracts exceeding $100,000 with state or metropolitan agencies (with potential equal pay certificate requirements at $500,000), contracts exceeding $100,000 with University of Minnesota for general obligation bond-funded capital projects, or contracts exceeding $250,000 with political subdivisions for general obligation bond-funded projects. Bidders must declare their certification status by selecting one of four options: currently holding a Workforce Certificate and/or Equal Pay Certificate; applying or having applied for certification with specified application dates; acknowledging the requirement to obtain certification or an approved exemption before contract execution; or claiming exemption based on not employing 40 or more employees on any single day during the prior 12 months in Minnesota or their primary state of business. The form requires completion of business information fields including vendor/supplier ID, business name, contracting agency name, authorized signatory details, and contact information.
The form serves as a compliance verification document for the related MNIT/AELSBOA RFP for a cloud-based licensing and compliance system with a June 22, 2026 proposal deadline. Vendors responding to this opportunity must complete and submit this declaration as part of their proposal package. The MDHR reserves the right to request documentation substantiating employee count claims for exempt companies. Assistance with form completion is available through the Minnesota Department of Human Rights Compliance at MDHR@state.mn.us. The form does not contain pricing information, funding amounts, or set-aside provisions; these elements are governed by the related RFP documentation and the individual contract terms negotiated with selected vendors.
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Other files
| File | Type | Posted |
|---|---|---|
| 4.3.2026_ptsamplecontractsandexhibits.pdf | ||
| Attachment_A_and_B.pdf | ||
| AELS_BOA_LCS.RFP_Final_5.19.26.pdf | ||
| rfpaddendum2_7.2.26.pdf | ||
| Attachment_E_FunctionalReq_SelfAssess3.13.26.xlsx | XLSX spreadsheet | |
| Attachment_C_Cost_Detail_4-15-25.docx | DOCX document | |
| rfpaddendum3_-_Clean.pdf | ||
| MNIT_AELSBOA_RFP_ITN_Licensure_Compliance_System.pdf | ||
| rfpaddendum1.pdf | ||
| rfpaddendum4_-_Clean.pdf | ||
| Attachment_F_AccessibilityTG.docx | DOCX document | |
| Replaced_Attachment_C_Cost_Detail_7.6.26_LCS.docx | DOCX document |
Show all 12
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Text version
[Title] 1
Attachment D
[Title] 2
Workforce and Equal Pay Declaration Page
This form is required for all businesses executing government contracts under the following:
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 Certificate)
Select all that apply:
We are a Certificate holder:
☐ Workforce Certificate under the name:
☐ Equal Pay Certificate under the name:
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): ____________________
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 and, if applicable, Equal Pay Certificate, or approved exemption by MDHR is required before a contract can be executed.
We are Exempt:
☐ We attest to MDHR 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. MDHR may request the https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/workforce-certificate/ 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/equalpay/ 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/equalpay/ 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/equalpay/
[Title] 3 names of our employees during the previous 12 months, the date of separation, if applicable, and the current employment status and count.
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.
Workforce and Equal Pay Declarations Page Rev. 3/7/2025
File details come from the government source that posted it. Updated .