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1 <br /> <br />CITY OF SAN LEANDRO <br />Living Wage Ordinance Self Verification Form for Providers of Personal Services <br /> <br />TO BE COMPLETED BY ALL PERSONS OR ENTITIES ENGAGING IN A CONTRACT FOR <br />SERVICES WITH THE CITY OF SAN LEANDRO. <br /> <br />The San Leandro Municipal Code Title 1, Chapter 6, San Leandro's Living Wage Ordinance (LWO), <br />provides that contractors who engage in a specified amount of business with the City (except where <br />specifically exempted) under contracts which furnish services to or for the City during the City's fiscal <br />year shall comply with all provisions of this ordinance. The LWO requires a City contractor to provide <br />City mandated minimum compensation to all eligible employees, as defined in the Ordinance. In order <br />to determine whether this contract is subject to the terms of the LWO, please respond to the questions <br />below. Please note that the LWO applies to those contracts where the contractor has achieved a <br />cumulative dollar contracting amount with the City. Therefore, even if the LWO is inapplicable to this <br />contract, change orders to this contract or the entering into of subsequent contracts may make them <br />subject to compliance with the LWO. Furthermore, the contract may become subject to the LWO if the <br />status of the Contractor's employees change (i.e. additional employees are hired) so that Contractor <br />falls within the scope of the Ordinance. <br /> <br />SECTION I <br /> <br />1. IF YOU ARE A FOR-PROFIT BUSINESS, PLEASE ANSWER THE FOLLOWING QUESTIONS <br />a. During the period of July 1 -June 30 of the current city fiscal year, have you entered into contracts, <br />including the present contract, bid, or proposal, with the City of San Leandro for a cumulative amount of <br />$25,000.00 or more? <br />YES ____ NO ____ <br />If no, this contract is NOT subject to the requirements of the LWO, and you may continue to Section II. If <br />yes, please continue to question 1(b). <br /> <br /> b. Do you have six (6) or more employees? <br />YES ____ NO ____ <br />If you have answered, “YES” to questions 1(a) and 1(b) this contract IS subject to the LWO. If you <br />responded "NO" to 1(b) this contract IS NOT subject to the LWO. Please continue to Section II. <br /> <br /> 2. IF YOU ARE A NON-PROFIT BUSINESS, AS DEFINED BY SECTION 501(C) OF THE INTERNAL <br />REVENUE CODE OF 1954, PLEASE ANSWER THE FOLLOWING QUESTIONS. <br />a. During the period of July 1 -June 30 of the current city fiscal year, have you entered into contracts, <br />including the present contract, bid, or proposal, with the City of San Leandro for a cumulative amount of <br />$100,000.00 or more? <br />YES ____ NO ____ <br />If no, this Contract is NOT subject to the requirements of the LWO, and you may continue to Section II. If <br />yes, please continue to question 2(b). <br /> <br />b. Do you have six (6) or more employees? <br />YES ____ NO ____ <br />If you have answered, “YES” to questions 2(a) and 2(b) this contract IS subject to the LWO. If you <br />responded "NO" to 2(b) this contract IS NOT subject to the LWO. Please continue to Section II on the <br />following page. <br />ATTACHMENT C <br />Page 39 of 5369