Attachment_D.pdf
PDF 154 KB Posted
- Attached to
- Comprehensive Child Welfare Information System
- Solicitation number
- 2000018525
- 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 for businesses executing government contracts with the State of Minnesota, Metropolitan agencies, the University of Minnesota, or Political Subdivisions. The form applies to contracts exceeding $100,000 with State or Metropolitan agencies (with an additional $500,000 threshold for Equal Pay Certificates), exceeding $100,000 with the University of Minnesota for general obligation bond funded capital projects (with an additional $500,000 threshold for Equal Pay), or exceeding $250,000 with Political Subdivisions for general obligation bond funded capital projects (with an additional $1,000,000 threshold for Equal Pay). Vendors must declare their Workforce and Equal Pay Certificate status, including whether they currently hold certificates, have applied for certificates with specific application dates, have not yet applied, or believe they qualify for an exemption.
The form requires vendors to provide business information including vendor/supplier ID, business name, contracting agency name, authorized signatory information, and contact details. Companies with fewer than 40 employees on a single day during the prior 12 months in Minnesota or their state of primary business location may be exempt from certification requirements, though the Minnesota Department of Human Rights retains the right to verify employee records and determine exemption eligibility. Vendors must complete and submit this declaration form prior to contract execution, and those without valid certificates or approved exemptions will be ineligible to proceed. Assistance with the form is available through the Minnesota Department of Human Rights Compliance office at MDHR@state.mn.us.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment_J.xlsx | XLSX spreadsheet | |
| Sample_Contract.docx | DOCX document | |
| Attachment_E.docx | DOCX document | |
| Attachment_N.docx | DOCX document | |
| CCWISRFP.pdf | ||
| Comprehensive_Child_Welfare_Information_System.pdf | ||
| Attachment_K.docx | DOCX document | |
| Attachment_B.docx | DOCX document | |
| Attachment_F.docx | DOCX document | |
| Attachment_L.docx | DOCX document | |
| Attachment_M.docx | DOCX document | |
| Attachment_G.xlsx | XLSX spreadsheet | |
| Attachment_C.xlsx | XLSX spreadsheet | |
| Attachment_H.xlsx | XLSX spreadsheet | |
| Attachment_I.xlsx | XLSX spreadsheet | |
| Exhibit_A_Supplement_1_Prevailing_Wage_Rates.pdf | ||
| Attachment_O.docx | DOCX document | |
| Attachment_A.docx | DOCX document |
Show all 18
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Text version
Workforce and Equal Pay Declarations Page Rev. 6/1/2023
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 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.
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 which 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.
☐ We believe our company is exempt because ___________________________________________________.
The Minnesota Department of Human Rights will review and determine if your company is exempt.
Business Information
Vendor/Supplier ID Vendor Email
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 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/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/
| Workforce and Equal Pay Declaration Page |
| Select one: |
| Select all that apply: |
| We are a certificate holder: |
| We are applying/have applied for the following certificate(s): |
| We have not applied for one or both certificates: |
| We are Exempt: |
Business Information
| State or Metropolitan agencies: Off |
| University of Minnesota: Off |
| Political Subdivisions: Off |
| Vendor/Supplier ID: |
| Vendor Email: |
| Name of Contracting Agency: |
| Business Name: |
| Authorized Signatory Name: |
| Title: |
| Date: |
| Email: |
| Phone: |
| We are a Workforce Certificate holder: Off |
| We are a Equal Pay Certificate holder: Off |
| We are applying/have applied for a Workforce Certificate: Off |
| We are applying/have applied for a Equal Pay Certificate: Off |
| What is the application date of your Workforce Certificate?: |
| What is the application date of your Equal Pay Certificate?: |
| We have not applied for one or both certificates: Off |
| 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: Off |
| We believe our company is exempt: Off |
| Why do you believe your company is exempt?: |
| What name is your Workforce Certificate under?: |
| What name is your Equal Pay Certificate under?: |
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