City And County Of San Francisco 12b And 12c Declaration: Nondiscrimination In Contracts And Benefits Form
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5CITY AND COUNTY OF SAN FRANCISCO
CONTRACT MONITORING DIVISION
S.F. ADMINISTRATIVE CODE CHAPTERS 12B & 12C
DECLARATION: NONDISCRIMINATION IN CONTRACTS AND BENEFITS
(CMD-12B-101)
The Equal Benefits Ordinance prohibits the City and County of San Francisco from contracting with vendors
that discriminate in the provision of benefits between employees with domestic partners and employees with
spouses, and between the domestic partners and spouses of such employees.
•
Domestic Partners are same-sex and opposite-sex couples registered with any state or local government
agency authorized to perform such registrations.
Domestic partnerships and marriages may only be verified to the same extent and in the same manner.
•
For example, waiting periods to qualify for benefits must be the same for domestic partners and spouses.
Domestic partner registry certificates must be recognized as fully equivalent to marriage certificates.
INSTRUCTIONS
STEP 1
Obtain a Vendor Number
If you have already been issued a vendor number by the City & County of San Francisco, go to Step 2.
To obtain a vendor number, contact Vendor File Support:
or (415) 554-6702.
STEP 2
Complete this 12B & 12C Declaration: Nondiscrimination in Contracts and Benefits form (CMD-12B-101)
STEP 3
Obtain the necessary supporting documentation
Most recent legal verification of employee count/firm structure, for example, a W-3 Form, DE 1 Form, DE 9 Form
or an annual San Francisco Payroll Expense Tax Statement.
(Please redact confidential employee information.)
A copy of a memorandum that has been distributed to your firm’s employees detailing the firm’s compliant
nondiscrimination and domestic partner benefit policies. An example of a memorandum that includes all
required confirmations is provided with this form and on the Contract Monitoring Division website.
Note: the memorandum is not a substitute for fully compliant incorporation of domestic partner language in
all benefit policies. Please contact the Contract Monitoring Division prior to distribution of the memorandum
if you have questions.
STEP 4
Submit the 12B & 12C Declaration: Nondiscrimination in Contracts and Benefits form (CMD-12B-101) and
all supporting documentation to:
or
Contract Monitoring Division, 30 Van Ness Avenue, Suite 200, San Francisco, CA 94102-6020
♦
Section 1. Vendor Information
DATE & TIME RECEIVED BY CMD
(FOR CMD USE ONLY)
Name of Firm: _____________________________________________________________
Name of Firm Contact Person: _______________________________________________
Phone: ______________________________________ Ext.: ______________________
E-mail Address: ___________________________________________________________
Vendor Number (if known): _________________________________________________
Federal ID or Social Security Number: _________________________________________
Approximate Number of Employees in the U.S. (Do not count yourself): ______________
Are any of your employees covered by a collective bargaining agreement or union trust fund?
Yes No
Union name(s): _____________________________________________________________________________________________
CMD-12B-101 (4-15)
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