Wage Payment Surety Bond Form - West Virginia Division Of Labor Page 4
Download a blank fillable Wage Payment Surety Bond Form - West Virginia Division Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Wage Payment Surety Bond Form - West Virginia Division Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4EMPLOYER’S AUTHORIZATION TO MAKE A DEMAND
FOR PAYMENT UPON THE SURETY BOND FOR
FAILURE TO PAY EMPLOYEE WAGES AND FRINGE BENEFITS
I, ____________________________________________________, as the Employer engaged in ☐ construction
Printed Name
work or ☐ the severance, production or transportation of minerals, understand that I am required by the Wage Payment and
Collection Act, W. Va. Code §21-5-14, to furnish a wage bond.
I understand that as long as I honor my statutory responsibility to pay employee wages and fringe benefits when
they are due, the Division of Labor will not make a demand upon the wage bond. If I default or otherwise fail to pay
employee wages and fringe benefits as required by the Wage Payment and Collection Act, I further understand that the
Division of Labor will make a demand on the Surety for payment under the bond. I hereby expressly authorize the Division
of Labor to use as much of the surety bond proceeds as necessary to pay employee wages and fringe benefits that are due
and owing.
I also understand that, if I default on my obligation to pay employee wages and fringe benefits, the Surety has the
right to take action against me to recover the amount of wages and fringe benefits it has paid to the Division of Labor on my
behalf.
_________________________________________
_____________________________
Original Signature
Date
State of _________________________________)
County of ________________________________), to-wit:
I, _____________________________________________________________, a Notary Public in and for
the county and state aforesaid, do hereby certify that _____________________________________________________,
who, as _______________________________________________, signed the writing above or hereto annexed,
for _______________________________________________________________, a corporation, has this day, in
my said county before me acknowledged the said writing to be the act and deed of said corporation.
Given under my hand this ____________ day of ______________________________________, 20 ______.
_______________________________________________
Notary Public
My Commission Expires _________________________________________
Notary Seal
Page 4 of 4
WVAGO Approved Form
Last Revised 9/25/14
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal