Form CMD-12b -101 "Chapter 12b Declaration: Nondiscrimination in Contracts and Benefits" - City and County of San Francisco, California

What Is Form CMD-12b -101?

This is a legal form that was released by the Contract Monitoring Division - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2015;
  • The latest edition provided by the Contract Monitoring Division - City and County of San Francisco, California;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CMD-12b -101 by clicking the link below or browse more documents and templates provided by the Contract Monitoring Division - City and County of San Francisco, California.

ADVERTISEMENT
ADVERTISEMENT

Download Form CMD-12b -101 "Chapter 12b Declaration: Nondiscrimination in Contracts and Benefits" - City and County of San Francisco, California

467 times
Rate (4.8 / 5) 23 votes
CITY 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:
vendor.file.support@sfgov.org
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:
 cmd.equalbenefits@sfgov.org 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)
CITY 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:
vendor.file.support@sfgov.org
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:
 cmd.equalbenefits@sfgov.org 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)
Section 2. Compliance Questions
Question 1. Nondiscrimination – Protected Classes
A. Does your firm agree it will not discriminate against its employees, applicants for
 YES  N0
employment, employees of the City, or members of the public on the basis of the
fact or perception of a person’s membership in the following categories?
Please note: a YES answer is required for compliance.
Race, Color, Creed, Religion, National origin, Ancestry, Age, Sex, Sexual orientation, Gender identity
(transgender status), Domestic Partner status, Marital status, Disability, AIDS/HIV status, Height, Weight
B. Does your firm agree to insert a similar nondiscrimination provision in any subcontract you
 YES  N0
enter into for the performance of a substantial portion of the contract you have with the City?
Please note: you must answer this question even if you do not intend to enter into any
subcontracts, and a YES answer is required for compliance.
Question 2. Nondiscrimination – Equal Benefits for Employees with Spouses and Employees with
Domestic Partners, and for the Spouse or Domestic Partner of an Employee
Questions 2A and 2B should be answered YES even if your employees pay some or all of the cost
of spousal or domestic partner benefits.
A. Does your firm provide or offer access to any employee benefits?
 YES  N0
(If your firm does not have employees, answer NO)
B. If you answered “Yes” to 2.A, are all of the benefits equally available to
 YES  N0
employees with domestic partners and employees with spouses?
(If your firm does not have employees, answer NO)
If you answered YES to either or both Questions 2A and 2B, please continue to Question 2C.
If you answered NO to both Questions 2A and 2B, please complete Section 3.
C. Please check all benefits that apply to your answers above and list in the “Other” line any additional benefits
not already specified. Note: some benefits are provided to employees because they have a spouse or domestic
partner, such as bereavement leave; other benefits are provided directly to the spouse or domestic partner,
such as dependent life insurance.
Available to
Available to/Affects
Available to/Affects
BENEFIT
Employees
Domestic Partners
Spouses
• Health Insurance
• Dental Insurance
• Vision Insurance
• Retirement (Pension, 401(k), IRA, etc.)
• Bereavement Leave
• Family Leave
• Parental Leave
• Employee Assistance Program
• Relocation and/or Travel
• Firm Discount, Facilities & Events
• Credit Union
• Child Care
• Dependent Life Insurance
• Short-Term/Long-Term Disability Insurance
• Accidental Death & Dismemberment Insurance
• Other (Please specify)
• Other (Please specify)
Firm 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
66
__ 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.
6
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
CMD.EqualBenefits@sfgov.org
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: www.sfgov.org/CMD.
 For assistance, please contact the Contract Monitoring Division at 415-581-2310.
CMD-12B-101 (4-15)
EXAMPLE OF 12B COMPLIANT MEMORANDUM TO EMPLOYEES
[FIRM LETTERHEAD]
To:
All [Firm Name] Employees
From: [Firm Representative Name, Title]
Re:
Domestic Partner Benefit Policy
Date: [Date]
[Firm Name] does not discriminate based on the following protected categories:
Race, Color, Creed, Religion, National origin, Ancestry, Age, Sex, Sexual Orientation,
Gender identity (transgender status), Domestic Partner status, Marital status, Disability,
AIDS/HIV status, Height, Weight
[Firm Name] offers the following employee benefits equally to employees with spouses and
employees with domestic partners, and to the spouses and domestic partners of such
employees [List all benefits provided by firm]:
 Health Insurance - [List each carrier]
• Dental Insurance - [List each carrier]
 Vison Insurance - [List each carrier]
 Retirement - [List each type of plan, for example, Pension, 401(k), 403(b), Simple IRA]
• Bereavement Leave
• Family Leave
• Parental Leave
• Employee Assistance Program
• Relocation and/or Travel
• Firm Discount, Facilities & Events
• Credit Union
• Child Care
 Dependent Life Insurance - [List each carrier]
 Short Term and/or Long-Term Disability Insurance - [List each carrier]
 Accidental Death & Dismemberment Insurance – [List each carrier]
Domestic partners are defined as same-sex and opposite-sex couples who are registered with
any state or local government domestic partner registry. Any requirements for proof of
relationship or waiting periods for domestic partnerships are also applied to marriages.
Domestic partner registry certificates are accepted as fully equivalent to marriage certificates.
(4-15)
CITY & COUNTY OF SAN FRANCISCO
CONTRACT MONITORING DIVISION
CHAPTER 12B EQUAL BENEFITS DOCUMENTATION GUIDE
Each benefit policy must include domestic partners and their children where spouses and stepchildren are referenced.
Blanket statements regarding your firm’s general domestic partner policy in a separate part of the employee handbook are insufficient.
Benefit Type
Guidelines
Standard Documentation
Health
Insurance confirmations must explicitly define
Acceptable: the cover page, eligibility section,
Dental
Domestic Partners as “same-sex and opposite-
and other relevant sections (such as the COBRA
sex couples who have registered with any state
Vision
section) of the Basic Plan Document, or you may
or local government domestic partnership
Dependent Life
submit a letter or email message from the
registry."
Long-term Disability
insurance carrier (contact us for an example).
Long-term Care
In addition, it must be confirmed that any
Unacceptable: letters from brokers, enrollment
Accidental Death & Dismemberment
requirements for proof of relationship for
forms, invoices, Summary Plan Descriptions.
Business Travel Accident
domestic partnerships are also applied to
Personal Travel Accident
marriages. For example, domestic partner
registry certificates must be recognized as fully
equivalent to marriage certificates.
Insurance policies that provide continuation
coverage to spouses and stepchildren must specify
that COBRA-like continuation coverage is available
to domestic partners and their children.
Pre-tax benefits may not comply.
Retirement (Pension, 401(k), etc.)
Plan documents must confirm that the distribution
A copy of the cover page and the distribution
options are the same for spouse and non-spouse or
section of the Summary Plan Description or
domestic partner beneficiaries (not who can be
Basic Plan Document of your 401(k) or pension
a beneficiary, but how the money is distributed upon
or savings plan(s). If you have a prototype plan,
the employee's death).
please include the Adoption Agreement.
Bereavement Leave
Where the term "spouse" is used, the term
A copy of your employee handbook policies.
Family Leave
"domestic partner" must be included.
When the term "Domestic Partners" is defined in
Family Medical Leave
an employee handbook, the following definition
The definition of "immediate family” must be defined
Military Caregiver Leave
must be used: “same-sex and opposite-sex
in the bereavement policy and if it includes in-laws,
Military Exigency Leave
couples who have registered with any state or
the equivalent members of a domestic partner's
Parental Leave
local government domestic partnership registry."
family must be explicitly included. An example of a
Relocation and Travel
Domestic partners may not be required to prove
compliant definition is: the employee's spouse or
Discounts, Facilities & Events
their relationship (for example, with an affidavit)
domestic partner; a parent, child, or sibling of the
or subject to waiting periods unless a firm
employee, spouse or domestic partner; and the
provides proof that spouses are subject to the
spouse or domestic partner of the employee's
same requirements. Domestic partner registry
parents, children, or siblings.
certificates must be recognized as fully
Federal law does not prevent recognition of
equivalent to marriage certificates.
domestic partners or their children in the FMLA and
Military policies.
Employee Assistance Program
References to spouses must include references to
A brochure or letter from the provider or policy
Credit Union
domestic partners or household members.
from the employee handbook.
Child Care
References to spouses must include references to
A brochure or letter from the provider.
domestic partners.
Pre-tax benefits may not comply.
Union
Separate documentation must be submitted for
Unions that recognize domestic partners have
benefits administered through collective bargaining
usually prepared a 1-page statement that is
agreements.
available upon request. If a union doesn't
recognize domestic partners, call the Equal
Benefits Unit at 415-581-2310 for assistance.
Other
If your firm offers other benefits, please specify what
Varies; call the Equal Benefits Unit at
they are on the 12B Declaration and provide
415-581-2310 for assistance.
documentation.
(4-15)