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DOMESTIC PARTNERSHIP CERTIFICATION FORM

THIS FORM MUST BE COMPLETED AND SUBMITTED AT TIME OF SUBMITTAL

FOR PROPOSER TO BE DEEMED RESPONSIVE

The Proposer, by virtue of the signature below, certifies that it is aware of the requirements of Section 2-

197.1 of the City of Cooper City’s Code of Ordinances, “Requirement for city contractors to provide equal benefits to domestic partners”, and certifies the following:

Please check only one below

1. The Proposer currently complies with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances and provides benefits to domestic partners of its employees and the partners’ dependents on the same basis as it provides benefits to employees’ spouses and the spouses’ dependents

2. The Proposer will comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of contract award and provide benefits to domestic partners of its employees and the partners’ dependents on the same basis as it provides benefits to employees’ spouses and the spouses’ dependents

3. The Proposer will not comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of award

4. The Proposer does not need to comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances at time of award because the following exemption applies:

Please check only one below The Proposer’s price bid for the initial contract term is $100,000 or less

The Proposer employs less than twenty-five (25) employees

The Proposer does not provide benefits to employees’ spouses or spouse’s dependents

The Proposer is a religious organization, association, society, or non-profit charitable or educational institution

The Proposer is a government entity

The Proposer cannot comply with the requirements of Section 2-197.1 of the City of Cooper City’s Code of Ordinances because it would violate the laws, rules or regulations of federal or state law or would violate or be inconsistent with the terms or conditions of a grant or contract with the United States or State of Florida. Indicate the law, statute or regulation .

(Attach explanation of its applicability)

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DOMESTIC PARTNERSHIP CERTIFICATION FORM (continued)

I, , of (Name) (Title) (Proposer)

Hereby attest that I have the authority to sign this notarized certification and certify that the above-referenced information is true, complete, and correct.

Signature Print Name

Personally Known: OR Identification Produced:

Type of Identification Produced:

(NOTARY SEAL)

STATE: COUNTY:

Sworn to (or affirmed) and subscribed before me this __________day of

, 20 , by: .