Fillable Subconractor Declaration Of Compliance Form printable pdf download

LW-5

LWO – SUBCONTRACTOR DECLARATION OF COMPLIANCE FORM

REQUIRED DOCUMENTATION FOR ALL SUB CONTRACTS SUBJECT TO LWO

This form must be signed within 90 DAYS of the execution of the subcontract and RETAINED by

the PRIME CONTRACTOR.

TO BE FILLED OUT BY THE PRIME CONTRACTOR:

1. Company Name: ________________________________ Company Phone Number: _____________________

2. Company Address:

3. Awarding Department:

4. Project Name:

IF A SUBCONTRACTOR FAILS TO COMPLETE AND SUBMIT THIS FORM TO PRIME CONTRACTOR ON THE CITY CONTRACT,

THE PRIME CONTRACTOR MAY BE DEEMED TO BE IN VIOLATION OF THE LWO AND SCWRO FOR FAILING TO ENSURE ITS

SUBCONTRACTOR’S COMPLIANCE WITH THE ORDINANCES. THIS MAY RESULT IN WITHHOLDING OF PAYMENTS DUE THE

PRIME CONTRACTOR, OR TERMINATION OF THE PRIME CONTRACTOR’S AGREEMENT WITH THE CITY.

THE PRIME CONTRACTOR MUST INFORM THEIR SUBCONTRACTORS OF THE FOLLOWING:

THE LIVING WAGE ORDINANCE (LWO) REQUIRES:

That a subcontractor (including a sublessee, a sublicensee, or a service contractor to a City financial assistance

recipient) that works on or under the authority of an agreement subject to Living Wage Ordinance (LWO)

must comply with all applicable provisions of the Ordinance unless specifically approved for an exemption.

THE LIVING WAGE ORDINANCE (LWO) REQUIRES THAT SUBJECT EMPLOYERS PROVIDE TO

EMPLOYEES:

As of July 1, 2016, a wage of at least

$11.27 per hour with health benefits

of $1.25 per hour, or

$12.52 per hour

without health benefits

(to be adjusted annually on July 1) (Regulation #4);

At least

12 compensated days off per year

for sick leave, vacation or personal necessity at the employee’s request

(pro-rated for part-time employees) (Regulation #4);

At least

10 additional days off per year of uncompensated time off

for sick leave (pro-rated for part-time

employees) (Regulation #4); and

Making

less than $12.00 per hour

information of their possible

right to the federal Earned Income Tax Credit (EITC)

and make available the forms required to secure advance EITC payments from the employer (Regulation #4).

THE LIVING WAGE ORDINANCE (LWO) ALSO REQUIRES EMPLOYERS:

To permit access to work sites for authorized City representatives to review the operation, payroll and related

documents, and to provide certified copies of the relevant records upon request by the City.

Not to retaliate

against any employee claiming non-compliance with the provisions of these Ordinances and to

comply with federal law

prohibiting retaliation for union organizing (Regulation #4). Refer to the LWO Rules and

Regulations, available from the Department of Public Works, Bureau of Contract Administration, Office of Contract

Compliance (OCC) website - , for details regarding the wage and benefit requirements of the Ordinance.

TO BE FILLED OUT BY THE SUBCONTRACTOR:

1. Company Name: ________________________________ Company Phone Number: ______________________

2. Company Address:

3. Type of Service Provided by Subcontractor to Prime:

4. Amount of Subcontract: ____________________ Subcontract Start Date: ___/___/___ End Date: ___/___/___

By signing this Declaration of Compliance, the subcontractor certifies that it will comply with all applicable provisions of the SCWRO, LWO, and their

implementing Rules and Regulations, including any amendments or revisions to the Ordinances and Regulations.

Print Name of Person Completing This Form

Signature of Person Completing This Form

Title

Phone #

Date

Form OCC/LW-5, Rev. 6/16

OFFICE OF CONTRACT COMPLIANCE, EEOE SECTION: (213) 847-2625

Subconractor Declaration Of Compliance Form

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