Attachment_D.pdf
PDF 154 KB Posted
- Attached to
- MNIT/DOC FAS Survey and Assessments Solutions
- Solicitation number
- 2000018539
- Issued by
- Minnesota
About this file
This is a Workforce and Equal Pay Declaration form issued by the Minnesota Department of Human Rights (MDHR), applicable to businesses executing government contracts with State or Metropolitan agencies, the University of Minnesota for general obligation bond-funded capital projects, or Political Subdivisions for general obligation bond-funded capital projects. The form requires contractors to declare their workforce and equal pay certificate status in relation to contract thresholds that vary by contracting entity: State or Metropolitan agencies require certificates for contracts exceeding $100,000 (Workforce Certificate) and $500,000 (Equal Pay Certificate); University of Minnesota contracts require certificates for amounts exceeding $100,000 and $500,000 respectively for general obligation bond-funded capital projects; and Political Subdivisions require certificates for contracts exceeding $250,000 (Workforce Certificate) and $1,000,000 (Equal Pay Certificate). Contractors must select whether they hold active certificates, have applied for certificates, have not applied for certificates, or qualify for exemption based on not employing 40 or more employees during the prior 12 months in Minnesota or their primary place of business.
The declaration form requires contractors to provide business information including vendor/supplier ID, business name, contracting agency name, authorized signatory details, and contact information. Companies that have not obtained required certificates must acknowledge that certification or approved exemption from MDHR is mandatory before contract execution. The MDHR retains the authority to review exemption claims and may request documentation including employee names, separation dates, and current employment status. Support for completion is available through the MDHR Compliance office at MDHR.Compliance@state.mn.us, with additional resources available on the Minnesota Department of Human Rights website regarding both Workforce Certificate and Equal Pay Certificate requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment_C_-_Cost_Detail.docx | DOCX document | |
| RFP_Template_Survey_and_Assessment_Solution_Final.docx | DOCX document | |
| ptsamplecontractsandexhibits.docx | DOCX document | |
| Attachment_E.xlsx | XLSX spreadsheet | |
| MNIT_DOC_FAS_Survey_and_Assessments_Solutions.pdf | ||
| Attachment_A_and_B.pdf |
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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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