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 the collective bargaining 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
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 the collective bargaining 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 8-7-06 Page 1 of 1 Exhibit D Program Monitoring Shelter Network Outreach and Case Management Services FY 2011-14 Contractor will provide to County on demand, all requested income and demographic data about the recipients of services under this Agreement. This data may include race, family size, income, sex and handicap status, if any, of the head of household. Contractor will participate in regular meetings with HSA-designated staff to develop and monitor Contractor’s progress by providing to HSA monthly financial statements and other required information. Contractor will provide County with an Annual Audit Report. The Audit report must include a statement of compliance with OMB Circular A -133 “Audits of States”, Local Governments and Non-Profit Organizations”. Exhibit E Outcome Based Management Initiative Shelter Network Outreach and Case Management Services FY 2011-14 Responsibilities relating to the County’s OBM Initiative: Contractor Responsibilities Contractor will engage in activities and supply information required to implement the County’s Outcome-Based Management and Budgeting (OBM) initiative. Activities include, but are not limited to: · Attending planning and informational meetings; · Developing program performance and outcome measurements; · Collecting and submitting data necessary to fulfill measurement requirements; · Participating in technical assistance and training events offered by the Human Services Agency and seeking technical assistance and training necessary to fulfill measurement requirements; · Participating in a review of performance and outcome information; and · Complyi...
EMPLOYEE JURY SERVICE. (check one or more boxes) 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 the collective bargaining agreement expires. 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. 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
EMPLOYEE JURY SERVICE. (check one or more boxes) 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 the collective bargaining agreement expires. 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. 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 8-7-06 Page 1 of 1 Form W-9(Rev. October 2007)Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Name (as shown on your income tax return) BurlingameHacienda Business name, if different from above Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) } Other (see instructions) } Exempt payee Address (number, street, and apt. or suite no.) 1012 El CaminoReal Requester’s name and address (optional) City, state, and ZIP code Burlingame,CA 94010 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Social security number Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is Employer identification number 37 1582024 your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.
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 less than $100,000 Contractor is a party to a collective bargaining agreement that began on (date) and expires on (date), and intends to comply when the collective bargaining 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 PRINTED NAME DATE TITLE ATTACHMENT ASSURANCE OF COMPLIANCE WITH SECTION 504 OF THE REHABILITATION ACT OF 1973, AS AMENDED The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)
EMPLOYEE JURY SERVICE. (check one or more boxes) Borrowers 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. Borrower complies with the County’s Employee Jury Service Ordinance.
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 the collective bargaining 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 8-7-06 Page 1 of 1 Exhibit D Program Monitoring Home and Hope FY 2010-13 Contractor will submit to the Human Services Agency, Shelter Services a Quarterly Performance Report within 30 days of the end of each quarter that will consist of two parts (Item 1 and 2):
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 the collective bargaining 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. EXHIBIT D COUNTY OF SAN MATEO Contractor’s Declaration Form I. CONTRACTOR INFORMATION Contractor Name: Jefferson Elementary School District Phone: Contact Person: Xxxxxxx Xxxxxx Fax: Address: 000 Xxxxxxx Xxxxxx Xxxx Xxxx, XX 00000
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 the collective bargaining 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 8-7-06 Page 1 of 1 Attachment H Health Insurance Portability and Accountability Act (HIPAA) Business Associate Requirements Definitions Terms used, but not otherwise defined, in this Schedule shall have the same meaning as those terms are defined in 45 Code of Federal Regulations section 160.103 164.304 and 164.501. (All regulatory references in this Schedule are to Title 45 of the Code of Federal Regulations unless otherwise specified.)
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 the collective bargaining 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 Exhibit F CHILD ABUSE REPORTING REQUIREMENT Child Abuse Prevention and Reporting Contractor agrees to ensure that all known or suspected instances of child abuse or neglect are reported to a child protective agency. Contractor agrees to fully comply with the Child Abuse and Neglect Reporting Act, Cal Pen Code 11164 et seq. Contractor will ensure that all known or suspected instances of child abuse or neglect are reported to an agency (police department, sheriff’s department, county probation department if designated by the county to receive mandated reports, or the county welfare department) described in Penal Code Section 11165.9. This responsibility shall include:
