Attachment_D_Workforce_Equal_Pay_Declaration_Page.pdf

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/

Business Information