CONTRACTOR has fully complied with all lawfully served wage and earnings assignment orders and notices of assignment and will continue to maintain compliance. Note: Failure to comply with state and federal reporting requirements regarding a contractor's employees or failure to implement lawfully served wage and earnings assignment orders or notices of assignment constitutes a default under the contract; and failure to cure the default within 90 days of notice by the County shall be grounds for termination of the contract. Principal owners can contact the Sacramento Department of Child Support Services at . (916) 875-7400 or (866) 901-3212, by writing to , 95826-9112, or by E-mailing ____________________________________ ___________________ CONTRACTOR DATE ____________________________________ Signed Name ____________________________________ Printed Name CONTRACTOR IDENTIFICATION FORM Contractor is exempt. Complete Name”, by” and only “Company “Completed “Date” If not exempt, CONTRACTOR TO COMPLETE FORM: Company Name Company Address Taxpayer ID Company Telephone Number Do you or anyone else own 25% or more of this Contractor/ Yes No Company? (Sole Proprietors answer yes) Yes No If so, is dependent health insurance available to/or through Contractor/Company? If YES to question #1, please complete the following as to each of individuals: Principal Name Social Security # Residence Telephone # Residence Address Principal Name Social Security # Residence Telephone # Residence Address Principal Owner Name Social Security # Residence Telephone # Residence Address Principal Owner Name Social Security # Residence Telephone # Residence Address
CONTRACTOR has fully complied with all lawfully served wage and earnings assignment orders and notices of assignment and will continue to maintain compliance. Note: Failure to comply with state and federal reporting requirements regarding a contractor's employees or failure to implement lawfully served wage and earnings assignment orders or notices of assignment constitutes a default under the contract; and failure to cure the default within 90 days of notice by the County shall be grounds for termination of the contract. Principal owners can contact the Sacramento Department of Child Support Services at (916) 875-7400 or (866) 901-3212, by writing to , 95826-9112, or by E-mailing . ____________________________________ ___________________ CONTRACTOR DATE ____________________________________ Signed Name ____________________________________ Printed Name CONTRACTOR IDENTIFICATION FORM Contractor is exempt. Complete “Company Name”, “Completed by” and “Date” only If not exempt, CONTRACTOR TO COMPLETE FORM: Company Name Company Address Taxpayer ID Company Telephone Number Do you or anyone else own 25% or more of this Contractor/ Company? (Sole Proprietors answer yes) If so, is dependent health insurance available to/or through Contractor/Company? Yes No Yes No If YES to question #1, please complete the following as to each of individuals: Principal Name Social Security # Residence Telephone # Residence Address Principal Name Social Security # Residence Telephone # Residence Address Principal Owner Name Social Security # Residence Telephone # Residence Address Principal Owner Name Social Security # Residence Telephone # Residence Address
RFQ-2018-009%20Released%20July%203.docx