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AGENT OR SUBCONTRACTOR AFFIDAVIT OF COMPLIANCE

WITH PREVAILING WAGE RATE DETERMINATION

This form must ONLY be filed with the Awarding Contractor indicated below.

Personally identifiable information may be used for secondary purposes. See s.15.04(1)(m), Stats. for details.

PROJECT NAME ____________________________________________

PROJECT # ___________ DETERMINATION # _________________

STATE OF _______________________)

DATE DETERMINATION ISSUED ____________________________

) SS.

COUNTY OF _____________________)

AWARDING CONTRACTOR __________________________________

DATE OF SUBCONTRACT ___________________________________

DATE WORK COMPLETED __________________________________

After being duly sworn, the person whose name and signature appears below hereby states under penalty

of perjury that:

(1) I am the duly authorized officer of the corporation, partnership, sole proprietorship or business

indicated below and have recently completed all of the work required under the terms and conditions

of a subcontract with the above-named awarding contractor and make this affidavit in accordance

with the requirements set forth in ss. 66.293(9)(b) or 103.49(4r)(b), Stats. and Ch. DWD 290 of the

Wisconsin Administrative Code in order to obtain FINAL PAYMENT from such awarding contractor.

(2) I have fully complied with all of the wage and hour requirements applicable to this project, including

all of the requirements set forth in the prevailing wage rate determination indicated above which was

issued for such project by the Department of Workforce Development on the date indicated above.

(3) I have received the required affidavit of compliance from each of my agents and subcontractors that

performed work on this project and have listed each of their names and addresses on the reverse side

of the this affidavit.

(4) I have full and accurate records which clearly indicate the name and trade or occupation of every

worker(s) that I employed on this project, including an accurate record of the hours worked and

actual wages paid to such worker(s).

(5) I will retain the records and affidavit(s) described in (3) and (4) above and make them available for

inspection for a period of at least three (3) years from the completion date indicated above at the

address indicated below and shall not remove such records or affidavit(s) without prior notification to

the awarding contractor indicated above.

SUBSCRIBED AND SWORN

_________________________________________________________________

BEFORE ME ON THIS

Name of Corporation, Partnership, Sole Proprietorship or Business

________________________________________________________________________

_____day of ________________, ______

Address (Include Street or P.O. Box, City, State and Zip Code

___________________________________

______________________________________________ _________________________

Signature of Notary Public

PRINT Name of Authorized Officer

Date Signed

State of _

________________________________

______________________________________________ (______)__________________

My Commission Expires___________

Signature of Authorized Officer

Telephone #

The statutory authority for the use of this form is prescribed in ss. 66.293(9)(b) and 103.49(4r)(b), Stats. The use of

this form is mandatory. The penalty for failing to complete this form is prescribed in s. 103.005(12), Stats.

ERD-10584 (N.1/97)

Form Erd-10584 - Agent Or Subcontractor Affidavit Of Compliance With Prevailing Wage Rate Determination - 1997

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