8-99 e-verify compliance form pdf fill-in.pdf
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- Solicitation number
- Not on record
- Issued by
- Montgomery County, Pennsylvania
About this file
This is a Commonwealth of Pennsylvania Public Works Employment Verification Form completed for Montgomery Township, Montgomery County, Pennsylvania, regarding the Supply and Installation of Front PTO, Front 3-Point Hitch, and 11-Foot or 12-Foot Plow for John Deere 6120M Tractor project. The form serves as certification that the contractor/subcontractor is in compliance with Pennsylvania's Public Works Employment Verification Act and utilizes the federal E-Verify Program operated by the United States Department of Homeland Security. The contractor must verify that all employees hired are authorized to work in the United States and commits to using E-Verify for all new hires within five business days of the employee start date throughout the duration of the public works contract. An authorized representative of the company must sign and attest that all information in the verification form is true and correct, with understanding that submission of false or misleading information subjects the company to sanctions provided by law.
The form requires documentation confirming the use of the federal E-Verify program for each new hire, which must be maintained in the event of investigation or audit. This verification form is a mandatory requirement that must be completed and returned to the contracting public body prior to contract award. The document establishes that Montgomery Township is the contracting public body and that the project involves equipment supply and installation services for township agricultural equipment. Failure to comply with E-Verify requirements or providing false information in connection with this verification can result in legal sanctions under Pennsylvania law.
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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
| Company Legal Name: |
| Doing Business As: |
| Street Address 1: |
| Street Address 2: |
| City: |
| State: |
| Zip Code: |
| Contractor: Off |
| Subcontractor: Off |
| Contracting Public Body: Montgomery Township |
| ContractProject Number: N/A |
| Project Description: Supply and Installation of Front PTO, Front 3-Point Hitch, and 11-Foot or 12-Foot Plow for John Deere 6120M Tractor |
| Project Location: Montgomery Township, Montgomery County, PA |
| Printed Name: |
| Phone Number: |
| Email: |
| Today's Date: |
| Name of Authorized Representative: |
| MM/DD/YYYY: |
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