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PRIME CONTRACTOR AFFIDAVIT OF COMPLIANCE

WITH PREVAILING WAGE RATE DETERMINATION

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

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

PROJECT NAME _________________________________________

PROJECT # ___________ DETERMINATION # ________________

STATE OF __________________)

DATE DETERMINATION ISSUED ___________________________

) SS.

COUNTY OF ________________)

AWARDING AGENCY_____________________________________

DATE OF CONTRACT _____________________________________

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 contract with the above-named

awarding agency and make this affidavit in accordance with the requirements set forth in ss. 66.293(9)(c) or

103.49(4r)(c), Stats. and Ch. DWD 290 of the Wisconsin Administrative Code in order to obtain FINAL PAYMENT

from such awarding agency.

(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 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 agency 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 _

_______________________________

__________________________________________ (_____)______________

Signature of Authorized Officer

Telephone #

My Commission Expires___________

The statutory authority for the use of this form is prescribed in ss. 66.293(9)(c) and 103.49(4r)(c), 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-5724 (R. 12/2000)

Form Erd-5724 - Prime Contractor Affidavit Of Compliance With Prevailing Wage Rate Determination - 2000

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