Form Erd-5719 - Application For Prevailing Wage Rate Determination Issued By The Wisconsin Department Of Workforce Development - 2013
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4State of Wisconsin
Application for Prevailing Wage Rate Determination
Department of Workforce Development
Issued By the Department of Workforce Development
Equal Rights Division
Personal information you provide may be used for secondary purposes. [Privacy Law Section 15.04 (1)(m),
Wisconsin Statutes].
The STATUTORY AUTHORITY for the use of this form is specified in Sections 66.0903 and 103.49, Wisconsin
Statutes, and Chapter DWD 290 of the Wisconsin Administrative Code. The use of this form is mandatory.
All pages must be completed. If you have questions, call (608) 266-6861.
There are three state prevailing wage laws that may apply to a construction project. One law applies to local
governmental units (Section 66.0903, Wis. Stats.). A second law applies to state agencies (Section 103.49, Wis.
Stats.). The third law applies to highway and bridge projects awarded by the Wisconsin Department of
Transportation (DOT). This last law is not under the jurisdiction of the Wisconsin Department of Workforce
Development and this application does not apply to those DOT projects.
You should obtain a project determination before awarding the prime contract. APPLY EARLY! ALLOW AT
LEAST 30 DAYS to have your non-electronic application processed. If you already awarded the prime contract,
you still must complete this application. Submit your application by using ONE of the following options:
1) Complete the application on line at: dwd.wisconsin.gov/er/prevailing_wage_rate/pw_online_
determinations.htm, which will immediately generate your project determination,
2) FAX the completed application to (608)267-4592, or
3) Mail the completed application to Equal Rights Division, PO Box 8928 Madison WI 53708.
1. The Owner of this Project is (check one only):
For DWD Use Only
A Local Governmental Unit (for e.g., town, city, county, public utility, school district,
technical college, sanitary sewer district)
Section 66.0903, Wis. Stats.
A State Agency
A Private Entity (for e.g., development company, investor, corporation)
Section 103.49, Wis. Stats.
If this project is jointly owned by any of the above, call the prevailing wage office at
Joint Project
608-266-6861 before completing the remainder of this application.
2. Project Owner Name (i.e., local governmental unit, state agency or private entity)
Owner Contact Name
Owner Contact Title
Owner Contact Mailing Address
City
State
Zip Code
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
3. If the answer in Box 1 is “A Private Entity,” then respond to each of the following:
a. Will the completed project be dedicated to or accepted by a local governmental unit?
Yes
No
b. Will the completed facility be leased, purchased, lease purchased or otherwise acquired by or dedicated to the State or a
state agency?
Yes
No
c. What is the name of the local governmental unit or state agency referred to in a. or b.?
d. In addition to all other information requested on this application, complete the contact information requested in Box 24.
4. What is the name of the project?
5. What is your project number for this project (if applicable)?
6. What is the EXACT location of the project?
County of ________________________
Select One:
City or
Village or
Town of _________________________________
7. What is the total estimated cost of this project (total cost
◄If the total estimated cost does not exceed the
includes labor, equipment and material)?
applicable project threshold; a prevailing wage project
determination is not required.
$
ERD-5719 (R. 6/2013)
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