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State of Wisconsin

Agent or Subcontractor Affidavit of Compliance

Department of Workforce Development

With Prevailing Wage Rate Determination

Equal Rights Division

Authorization for this form is provided under Sections 66.0903(9)(b), 66.0904(7)(b) and 103.49(4r)(9b),

Wisconsin Statutes. The use of this form is mandatory. The penalty for failing to complete this form is

prescribed in Section 103.005(12), Wisconsin Statutes.

Personal information you provide may be used for secondary purposes [Privacy Law, Section 15.04(1)(m),

Wisconsin Statutes].

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

Project Name

DWD Determination Number

Project Number (if applicable)

State Of __________________)

Date Determination Issued

Date of Subcontract

)SS

Awarding Contractor

County Of _________________)

Date Work Completed

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

perjury that



I am the duly authorized officer of the corporation, partnership, sole proprietorship or business indicated

below. We have recently completed all of the work required under the terms and conditions of a

subcontract with the above-named awarding contractor. We make this affidavit in accordance with the

requirements set forth in Section 66.0903(9)(b), 66.0904(7)(b) or 103.49(4r)(b), Wisconsin Statutes and

Chapter DWD 290 of the Wisconsin Administrative Code in order to obtain FINAL PAYMENT from such

awarding contractor.



I have fully complied with the entire 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.



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 page 2 of this

affidavit.



I have full and accurate records that 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).

I will retain the records and affidavit(s) described 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.

Name of Corporation, Partnership, Sole Proprietorship, Business, State Agency or Local Governmental Unit

Street Address or PO Box

City

State

Zip Code

Telephone Number

(

)

Print Name of Authorized Officer

Date Signed

Authorized Officer Signature

ERD-10584 (R. 11/2010)

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

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