IFB_5300_BYS1054_ATT_6_v1.docx

CITY OF AUSTIN TEXAS

WORKPLACE CONDITIONS CODE AFFIDAVIT

This form verifies compliance with the City of Austin’s Workplace Conditions Code by requiring potential vendors to provide relevant information regarding the supply chain of the apparel products and laundering services that the City purchases. A complete set of Contact and Payroll information is required for each facility involved in the production of goods or provision of services covered by the City of Austin Workplace Conditions Code. The City of Austin’s Workplace Conditions Code is governed by Ordinance No. 20070621‐152, located here:

https://services.austintexas.gov/edims/document.cfm?id=104087.

By submitting this form, the undersigned agrees to the following:

· You declare that, to the best of your knowledge, your operations and those of your supply chain partners (through point‐of‐assembly) utilized to supply uniforms/apparel and laundering services to the City are in full compliance with the City’s Workplace Conditions Code. You also acknowledge that any changes in the terms of your compliance, including any modification to your supply chain partners and/or locations, shall be submitted to the City of Austin’s Financial Services Department within 15 days of such changes taking place. During the term of the contract, should the City discover that any of the information or declarations made on this form are false, the City may impose appropriate sanctions and/or remedies for breach of contract.

· You certify that each of the prime contractor’s suppliers and subcontractors has been furnished with a copy of the City of Austin’s Workplace Conditions Code. Additionally, you certify that each of the prime contractor’s suppliers and subcontractors has been instructed to post a copy of the code, including a procedure for filing complaints, in a location that is visible, obvious, and accessible in the workplace and translated into each worker’s first language.

· You agree to notify the City of Austin’s Financial Services Department, the authorized contact person for this solicitation, and the assigned departmental contract manager (if applicable) of any claims or legal actions related to discrimination or worker wages, hours, or working conditions filed against you in any local, state, or federal administrative agency or court in the preceding five years. This agreement will remain in effect throughout the term of the contract.

Part 1 ‐ Solicitation Information (Required) Solicitation No.:

Part 2 ‐ Prime Contractor Information (Required) Company Name: Street Address: City: State: Zip: Contact Person Name and Title: Phone Number: Email Address:

Part 3 – Facility Contact and Payroll Information (Required) The information being requested regarding wages, benefits, payroll deductions, and working hours applies for non‐ supervisory production employees. When listing regular payroll deductions, include a description of the deduction, and either the deduction percentage (%) or the deduction amount in U.S. dollars ($). Attach additional copies of this form, and any supporting documents, as necessary.

SUBMITTAL – Workplace Conditions

SUBMITTAL – Workplace Conditions Page 2 of 2

Number of normal working hours per day: ; Per week: Number of actual working hours per day: ; Per week: Description of overtime policy (if any):

Number of normal working hours per day: ; Per week: Number of actual working hours per day: ; Per week: Description of overtime policy (if any):

Number of normal working hours per day: ; Per week: Number of actual working hours per day: ; Per week: Description of overtime policy (if any):

Part 4 ‐ Signature (Required) I declare under penalty of perjury under the laws of the State of Texas that the information provided on this form and required attachments (as indicated) is true and correct, and that I am authorized to bind this entity contractually.

Signature Date Printed Name image1.png