Affidavit_of_Wages_Paid_(5).pdf

AFFIDAVIT OF WAGES PAID

To Be Completed After Construction Is Complete

All FIELDS ARE REQUIRED

FORM MUST BE SENT TO THE CONTRACTING AGENCY

General Contractor Information Company Name:

Address:

City: State: Zip:

Phone: Fax: E-Mail:

Estimated Completion Date: State Wage Decision Number:

Project Title:

Project Physical Address:

Print Name:

General Contractor Signature:

Sub Contractor Information

Date you completed work on this project:

Company Name:

Address:

City: State: Zip:

Phone: Fax: E-Mail:

Sub Contractor Signature:

2nd, 3rd, etc. Tier Sub Contractor Information

Date you completed work on this project:

Company Name:

Address:

City: State: Zip:

Phone: Fax: E-Mail:

Tier Signature:

I hereby certify that the above information is correct and that all workers I employ on this public works project were paid no less than the Prevailing Wage Rate(s) as determined by the Department of Workforce Solutions, Labor Relations Division for this project as identified by the State Wage Decision Number. I understand that contractors who violate Prevailing Wage Laws (i.e., incorrect job classification, improper payment of prevailing wages, and/or overtime, etc.), are subject to debarment procedures and shall be required to pay any back wages due to workers. (Ref. Labor Relations Division Public Works Minimum Wage Act Policy Manual (11.1.2 NMAC) & Public Works Minimum Wage Act (13-4-11 through 13-4-18, NMSA 78)).

Contractor’s Signature Date

(Revised 08/23/13)

INSTRUCTIONS FOR COMPLETING AFFIDAVIT OF WAGES PAID

GENERAL CONTRACTOR

1. Enter general contractor information and provide signature.

2. Enter State Wage Decision Number as listed in bid documents. (Example: BE 13-0123 B)

3. Enter project title - listed in bid documents.

4. Enter project physical address - exact location of project (job site).

5. Enter completion date of project.

6. All Affidavits’ must be sent to the Contracting Agency.

SUB CONTRACTOR

1. Enter general contractor information, but general contractor signature is not needed.

2. Enter sub contractor information as indicated and provide signature.

3. Enter sub contractor completion date.

NOTE: A separate signed form is needed for each contractor.

2ND, 3rd, etc TIER SUB CONTRACTOR

1. Enter sub contractor information, subcontractor signature is not needed.

2. Enter 2nd tier sub contractor information and provide signature.

3. Enter 2nd tier contract completion date.

(Revised 8/23/13)