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State of Wisconsin

Prime Contractor Affidavit of Compliance

Department of Workforce Development

Equal Rights Division

With Prevailing Wage Rate Determination

Labor Standards Bureau

NOTICE REQUIRED UNDER Section 15.04(1) (m), Wisconsin Statutes. Authorization for this form is provided under

Sections, 66.0903(9) (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. Personally identifiable information

may be used for secondary purposes.

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

Project Name

Project Number

Determination Number

State Of________________)

Date Determination Issued

Date of Contract

)SS

Awarding Agency

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 and have recently completed all of the work required under the terms and conditions of a contract

with the above-named awarding agency and make this affidavit in accordance with the requirements set

forth in Section 66.0903(9)(c) or 103.49(4r)(c), Wisconsin Statutes and Chapter DWD 290 of the Wisconsin

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

•

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.

•

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 agency indicated

above.

Name of Corporation, Partnership, Sole Proprietorship or Business

Street Address or P O Box

City

State

Zip Code

Telephone Number

(

)

Print Name of Authorized Officer

Date

Signed

Signature of Authorized Officer

ERD-5724 (R. 11/2005)

Form Erd-5724 - Prime Contractor Affidavit Of Compliance With Prevailing Wage Rate Determination

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