_J_Contractor's_Declaration_Form_Hazardous_Materials.pdf
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- Attached to
- Job Order Contract for Asbestos Abatement w/ Hazardous Materials (JOC 2619 and JOC 2621)
- Solicitation number
- 2026-RFP-00104
- Issued by
- San Mateo County, California
About this file
This is a Contractor's Declaration Form for the County of San Mateo related to a Job Order Contract for Hazardous Materials services at various County-owned facilities (Project Nos. JOC 2619, 2620, and 2621). The form must be completed in full and submitted with the bid and serves as a compliance verification document for contractors responding to this solicitation.
The form requires contractors to declare their compliance status across four primary areas: Equal Benefits, Non-Discrimination, and Employee Jury Service. For contracts exceeding $5,000, contractors must certify whether they comply with the County's Equal Benefits Ordinance by offering equal benefits to employees with spouses and domestic partners, providing cash equivalent payments in lieu of benefits, or claiming an exemption. Contractors must also declare whether any discrimination findings have been issued against them within the past year by the Equal Employment Opportunity Commission, Fair Employment and Housing Commission, or other investigative entities. For contracts exceeding $100,000, contractors must confirm adherence to the County's Employee Jury Service Ordinance, which requires written policies providing up to five days of regular pay for employees performing jury service in San Mateo County. The form concludes with a perjury declaration that must be signed by an authorized representative of the contracting entity, including name, title, and date.
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CONTRACTOR’S DECLARATION FORM
THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE BID
Project: Job Order Contract for Hazardous Materials at various County of San Mateo owned facilities for Project No. JOC 2619, 2620 and 2621
I CONTRACTOR INFORMATION
Contractor Name: Phone:
Contact Person: Fax:
II EQUAL BENEFITS (check one or more boxes) Contractors with contracts in excess of $5,000 must treat spouses and domestic partners equally as to employee benefits.
Contractor complies with the County’s Equal Benefits Ordinance by:
offering equal benefits to employees with spouses and employees with domestic partners.
offering a cash equivalent payment to eligible employees in lieu of equal benefits.
Contractor does not comply with the County’s Equal Benefits Ordinance.
Contractor is exempt from this requirement because:
Contractor has no employees, does not provide benefits to employees’ spouses, or the contract is for $5,000 or less.
Contractor is a party to a collective bargaining agreement that began on (date) and expires on (date), and intends to offer equal benefits when said agreement expires.
III NON-DISCRIMINATION (check appropriate box)
Finding(s) of discrimination have been issued against the Contractor within the past year by the Equal Employment Opportunity Commission, Fair Employment and Housing Commission, or other investigative entity. Please see attached sheet of paper explaining the outcome(s) or remedy for the discrimination.
No finding of discrimination has been issued in the past year against the Contractor by the Equal Employment Opportunity Commission, Fair Employment and Housing Commission, or any other entity.
IV EMPLOYEE JURY SERVICE (check one or more boxes) Contractors with original or amended contracts in excess of $100,000 must have and adhere to a written policy that provides its employees living in San Mateo County up to five days regular pay for actual jury service in the County.
Contractor complies with the County’s Employee Jury Service Ordinance.
Contractor does not comply with the County’s Employee Jury Service Ordinance.
Contractor is exempt from this requirement because:
the contract is for $100,000 or less.
Contractor is a party to a collective bargaining agreement that began on (date) and expires on (date), and intends to comply when said agreement expires.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I am authorized to bind this entity contractually.
Signature Name
Date Title
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