3-Public Works Compliance Verification Form.pdf
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- Solicitation number
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- Issued by
- Butler County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use in connection with the John Roebling's Historic Wire Rope Workshop Restoration project in Saxonburg, Pennsylvania. The form is required to be completed and submitted by contractors and subcontractors prior to contract award. The project involves design-build foundation renovation and site drainage improvements for the historic Roebling Wire Rope Shop, constructed in the 1840s, with work including architectural and engineering design, structural stabilization of the existing stone and timber frame, masonry repairs, water infiltration remediation, and site drainage improvements. All bidding contractors must provide signed and sealed architectural, engineering, and final permit drawings to Codesys Code Consulting, with design costs to be broken out separately for reimbursement through grant funding.
The verification form requires contractors and subcontractors to affirm compliance with Pennsylvania's Public Works Employment Verification Act through enrollment and utilization of the federal E-Verify Program operated by the United States Department of Homeland Security. Contractors must verify that all employees hired are authorized to work in the United States and commit to utilizing E-Verify for each new hire within five business days of the employee start date throughout the duration of the contract. Documentation of E-Verify usage must be maintained for potential investigations or audits. The form requires submission of company information, authorized representative signatures, contact details, and certification that all information provided is true and accurate, with false or misleading information subject to legal sanctions. The project is partially financed through a grant from the Commonwealth Financing Authority of Pennsylvania.
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Text version
Street Address 2
City State Zip Code
Doing Business As:
(if different from Legal Name)
Commonwealth of Pennsylvania Public Works Employment Verification Form
Complete and return the form to the contracting Public Body prior to the award of the contract.
Company Legal Name: ___________________________________________________________
Mailing Address: ______________________________________________________
Check one: Contractor Subcontractor
Contracting Public Body: _________________________________________________________
Contract/Project Number: ________________________________________________________
Project Description: _____________________________________________________________
Project Location: _______________________________________________________________
Date Enrolled in E-Verify (MM/DD/YYYY): ___________________________________________ As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of today’s date, __________________________, our company is in compliance with the Public Works Employment Verification Act (‘the Act’) through utilization of the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. To the best of my/our knowledge, all employees hired are authorized to work in the United States.
It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.
I,____________________________________________, authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.
Authorized Representative Signature Date of Signature
Printed Name: _________________________________________________________________
Phone Number: ______________________ Email: ____________________________________
Street Address 1
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| Contractor: Off |
| Subcontractor: Off |
| Contracting Public Body: |
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| Printed Name: |
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| Today's Date: |
| Name of Authorized Representative: |
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