Workforce___Equal_Pay_Declaration_Form.pdf
PDF 178 KB Posted
- Attached to
- DNR RFB Summer Gravel Pit Crushing & Stockpiling
- Solicitation number
- 2000018478
- Issued by
- Lake County, Minnesota
About this file
This is a Prime Contractor Response Form for Workforce and Equal Pay Declaration requirements issued by the Minnesota Department of Human Rights for use with state and local government contracts. The form applies to contractors executing contracts with State or Metropolitan agencies exceeding $100,000 (Workforce Certificate requirement) and $500,000 (Equal Pay Certificate requirement), University of Minnesota for general obligation bond funded capital projects exceeding $100,000 and $500,000 respectively, and Political Subdivisions for general obligation bond funded capital projects exceeding $250,000 and $1,000,000 respectively. Contractors must declare their certification status by selecting one of four options: current certificate holder status, active application for certification with application dates, non-application acknowledgment with commitment to obtain certificates before contract execution, or exemption based on having fewer than 40 employees on a single day during the prior 12 months in Minnesota or their primary place of business.
The form requires submission of business information including Vendor/Supplier ID, Business Name, Contracting Agency Name, Authorized Signatory Name and Title, Date, Signature, Email, and Phone Number. Contractors should direct inquiries regarding form completion to the Minnesota Department of Human Rights Compliance at Compliance.MDHR@state.mn.us. Certification is mandatory before contract execution for all applicable procurements, and the Minnesota Department of Human Rights retains the right to request employee records and verification of employment status and counts to confirm exemption claims or eligibility determinations.
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PRIME CONTRACTOR RESPONSE FORM
Workforce and Equal Pay Declaration Page
This form is required for all businesses executing government contracts under the following:
PART 1 - SELECT ALL THAT APPLY:
1.01 WE ARE A CERTIFICATE HOLDER:
☐ Workforce Certificate under the name:
☐ Equal Pay Certificate under the name:
1.02 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):
1.03 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.
1.04 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 where 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.
PART 2 - BUSINESS INFORMATION
Vendor/Supplier ID 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
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 mailto: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/equalpay/ https://mn.gov/mdhr/certificates/workforce-certificate/ https://mn.gov/mdhr/certificates/equalpay/ https://mn.gov/mdhr/certificates/equalpay/
| PART 1 - Select all that apply: |
| 1.01 We are a certificate holder: |
| 1.02 We are applying/have applied for the following certificate(s): |
| 1.03 We have not applied for one or both certificates: |
| 1.04 We are Exempt: |
PART 2 - Business Information
File details come from the government source that posted it. Updated .