City And County Of San Francisco 12b And 12c Declaration: Nondiscrimination In Contracts And Benefits Form Page 3
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5Firm Name___________________________________________
D. Please initial all statements below that apply to your firm. Please note: in addition, a YES answer is required for compliance.
__ Domestic partners are defined as same-sex couples and opposite-sex couples registered with
YES
N0
__
any state or local registry and verify their relationship in the same manner as spouses.
__ A memorandum detailing our firm’s domestic partner policies has been distributed to employees. YES
N0
__ The employee handbook includes domestic partner language wherever spouses are referenced.
YES
N0
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__ The children of domestic partners are explicitly included in all policies that recognize stepchildren. YES
N0
__ All insurance plans contain language that recognizes spouses and domestic partners equally.
YES
N0
____
YES
N0
__ All retirement, 401(k) and similar plans explicitly provide the same distribution choices for
__
spousal and domestic partner or nonspousal beneficiaries.
Note: If you can’t offer a benefit in a nondiscriminatory manner because of reasons outside your control, (e.g., there are no
insurance providers in your area willing to offer domestic partner coverage) you may be eligible for Reasonable Measures
compliance. To comply on this basis, you must agree to pay a cash equivalent, submit a completed Reasonable Measures
Application Form (CMD-12B-102) with all necessary attachments, and have your application approved by the Contract
Monitoring Division. For more information, see the Rules of Procedure or contact the Contract Monitoring Division.
COMPLIANCE AUDITS AND REQUIRED DOCUMENTATION
The City and County of San Francisco regularly audits
firms to verify that the answers on this form are complete and accurate.
Please see the Chapter 12B Equal Benefits Documentation Guide for a detailed description of compliant documentation.
To be certified under Chapters 12B & 12C you must submit proper documentation confirming that your firm has already
fully implemented equal benefits for employees with spouses and employees with domestic partners, and between the
spouses and domestic partners of such employees. In addition to a compliant CMD-12B-101 Declaration, you must submit
legal verification of your firm’s employee count and a copy of your compliant memorandum to employees that explains
your firm’s nondiscrimination and domestic partner benefit policies. Note: the memorandum is not a substitute for fully
compliant incorporation of domestic partner language in your firm’s benefit policies. You may also be required to provide
benefit documentation to verify that your firm does not discriminate in the provision of benefits. Such documentation may
include your employee handbook and confirmations from your insurance, union and retirement documents. Failure to
offer benefits in accordance with the San Francisco Chapter 12B Equal Benefits Ordinance may result in suspension of
your firm’s compliance status, financial penalties and/or the inability to contract with the City and County of San Francisco.
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♦
Section 3. Execute this CMD-12B-101 Declaration
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.
Executed this ________ day of ____________________ in the year ___________ , at ___________________________, __________
(City)
(State)
Signature
Mailing Address
Name of Signatory (please print)
City, State, Zip Code
Title
Submit this form and supporting documentation to: Contract Monitoring Division, 30 Van Ness Ave., Suite 200, San Francisco,
CA 94102-6020, or to
or to the City department that sent it to you if the department so requests.
Resource Materials and additional copies of this form may be found at:
For assistance, please contact the Contract Monitoring Division at 415-581-2310.
CMD-12B-101 (4-15)
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