60-Doc 00 73 00 05 - Appendix B - Public Works Employment Verification Form.pdf
PDF 63 KB Posted
- Attached to
- 2201256.01 - Whistlestop Park
- Solicitation number
- US.160528
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a Public Works Employment Verification Form issued by the Commonwealth of Pennsylvania for use with public works contracts. The form is designed for contractors and subcontractors to certify compliance with the Public Works Employment Verification Act and confirm participation in the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. Contractors must complete the form for their respective contract or project, providing business information, project details, and project location. The authorized representative must attest that all employees hired after January 1, 2013 are authorized to work in the United States and affirm that the company will utilize the federal E-Verify Program to verify employment eligibility for all new hires within five business days of the employee start date throughout the duration of the public works contract.
The form requires contractors to maintain documentation confirming E-Verify usage for each new hire in the event of investigation or audit. Submission of false or misleading information on the verification form subjects the contractor to sanctions provided by law. The form must be signed by an authorized representative of the contracting company and is applicable to all public works projects in Pennsylvania, including the referenced Whistlestop Park project (Contract 2022-01256.01) being managed by Montgomery Township, which is subject to the provisions of Act 127 Pennsylvania Public Works Employment Verification as amended.
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Text version
COMMONWEALTH OF PENNSYLVANIA
PUBLIC WORKS EMPLOYMENT VERIFICATION FORM
Date _______________________
Business or Organization Name (Employer)_________________________________________________
Address _____________________________________________________________________________
City _____________________________________ State_____________ Zip Code ________________
Contractor {dzōŎƻƴǘNJŀŎǘƻNJ όŎƘŜŎƪ ƻƴŜύ
Contracting Public Body _______________________________________________________________
Contract/Project No ___________________________________________________________________
Project Description ____________________________________________________________________
Project Location ______________________________________________________________________
As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of the above 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 post
January 1, 2013 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: |
| Address: |
| City: |
| State: |
| Zip Code: |
| Contracting Public Body: |
| ContractProject No: |
| Project Description: |
| Project Location: |
| Name: |
| Business or Organization Name - Employer: |
| Signature: |
| Check Box1: Off |
| Check Box2: Off |
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