WORKFORCE AND EQUAL PAY DECLARATION 
This form is required for all businesses executing government contracts under the following: 
 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 Certificate)

Select all that apply: 
1. We are a Certificate holder: 
	Workforce Certificate under the name:      
	Equal Pay Certificate under the name:      
	If your contract could be in excess of $100,000, submit the Workforce Certificate with all Solicitation materials.  If your contract could be in excess of $500,000, submit both the Workforce Certificate and Equal Pay Certificate with all Solicitation materials.  
2. 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):      
	If your contract could be in excess of $100,000, the Workforce Certificate must be submitted to Minnesota Housing prior to contract execution.  If your contract could be in excess of $500,000, both the Workforce Certificate and Equal Pay Certificate must be submitted to Minnesota Housing prior to contract execution. 
3. 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 and, if applicable, Equal Pay Certificate, or approved exemption by MDHR is required before a contract can be executed. 

4. We are Exempt: 
	We attest to MDHR 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.  MDHR 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.
Business Information: 
By signing this statement, I certify that the information provided is accurate and that I am authorized to sign on behalf of the Company. 

     	     	     	
Vendor/Supplier ID	Business Name	Name of Contracting Agency	
     	     	     	
Authorized Signatory Name	Title	Date	
     	     	     	
Signature	Email                                                    	Phone	

For assistance with this form, contact the Minnesota Department of Human Rights at: 651-539-1095 (Metro), 1-800-657-3704 (toll free), 711 or 1-800-627-3529 (MN Relay) or email at compliance.MDHR@state.mn.us.