HUD-Federal-Forms-over-200k.pdf

City of Pasadena Buy America Preference (BAP) Certification

Required for federally funded infrastructure contracts subject to Build America, Buy America (BABA)

Project Information

Contractor /Company Name

Bid or RFP Number

Project Name

Federal Funding Source(s)

This “Buy America Preference Certification” is used to certify that, as required by the Build America, Buy America (BABA) Act, all of the iron, steel, manufactured products, and construction materials incorporated into an infrastructure project are produced in the United States, unless exempted by a HUD general waiver or a project-/product-specific waiver approved by the Made in America Office (MIAO) at the Office of Management and Budget (OMB). This certification must be completed and submitted with your bid or proposal if the scope includes construction, alteration, maintenance, or repair of infrastructure and is federally funded with $250,000 or more. The City reserves the right to request updated certification during project implementation.

For covered materials not otherwise exempted from the Buy America Preference (BAP), the undersigned certifies the following:

• All iron and steel used in the project are produced in the United States. This means all manufacturing processes, from the initial melting stage through the application of coatings, occurred in the United States;

• All manufactured products used in the project are produced in the United States. This means the manufactured product was manufactured in the United States, and the cost of the components of the manufactured product that are mined, produced, or manufactured in the United States is greater than 55 percent of the total cost of all components of the manufactured product, unless another standard that meets or exceeds this standard has been established under applicable law or regulation for determining the minimum amount of domestic content of the manufactured product;

• All construction materials used in the project are manufactured in the United States. This means that all manufacturing processes for the construction material occurred in the United States.

By signing this form, the contractor affirms that they will maintain documentation verifying compliance with the Buy America Preference for all covered materials. Acceptable supporting documentation includes (but is not limited to):

- Manufacturer certifications showing country of origin

- Invoices identifying U.S. production

- Material cut sheets or product data

- Bills of lading or shipping documentation

- Photos or site logs verifying installation of compliant materials

These records must be retained for five (5) years and provided to the City of Pasadena or HUD upon request. Noncompliance may result in withheld payments, disallowed costs, or termination for cause.

I certify that all iron, steel, manufactured products, and construction materials incorporated into the project will be produced in the United States in compliance with the Buy America Preference, or that an applicable waiver (including general waivers) applies. I agree to retain documentation supporting this certification and to submit it to the City of Pasadena or HUD upon request.

Signature Title Date

Worker’s Compensation Certification State of California Compliance Form – To be submitted with Bid

I certify, by signature below, that I am aware of the provisions of Section 3700 of the California Labor Code which require every employer to be insured against liability for worker’s compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract.

Date: ________________ Project RFP Number: _______________________

Project Name: _________________________________________________________

Company Name: _______________________________________________________

Address: _____________________________________________________________

Print Name: __________________________________________________________

Title: ________________________________________________________________

Signature: ____________________________________________________________

Federal Lobbyist Certification Federal Compliance Form – To be submitted with Bid

Name of Firm: ____________________________________________________________

Address: ________________________________________________________________

State: ______ Zip Code: ___________ Telephone Number: ( ) ______________

Acting on behalf of the above named firm, as its Authorized Official, I make the following Certification to the U. S. Department of Housing and Urban Development and the body awarding this federally assisted construction contract:

1. No Federal appropriated funds have been paid by or on behalf of the above named firm to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of and Federal grant, loan or cooperative agreement, and any extension, continuation, renewal, amendment, or modification thereof, and;

2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee or any agency, a Member of Congress an officer or employee of Congress or an employee of a Member of Congress in connection with this Federal contract, grant loan, or cooperative agreement, the above named firm shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions, and;

3. The above name firm shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreement) and that all sub-recipients shall certify and disclose accordingly.

NOTE: This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into the transaction imposed by Section 1352 Title 31, U. S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Authorized Official:

___________________________________ By: _____________________________ (Contractor/Subcontractor) (Signature)

(Date) (Title)

Past Performance Certification Federal Compliance Form – To be submitted with Bid

The �bidder, �proposed sub-contractor, hereby certifies that he/she �has, �has not, participated in a previous contract or subcontract subject to the Equal Opportunity Clause, as required by Executive Orders 10925, 11114, or 11246, and that he/she �has, �has not, filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance, a Federal Government contracting or administering agency, or the former President’s Committee on Equal Employment Opportunity, all reports due under the applicable filing requirements.

Date: _________ Project Number: _____________ Contract Award: $___________

Awarding Agency: ______________________________________________________

Contractor Name: __________________________ Total Number of Employees______

Affiliate Company: ______________________________________________________

By: __________________________________________________________________

Title: _________________________________________________________________

NOTE: The above certification is required by the Equal Employment Opportunity Regulations of the Secretary of Labor (41 CFR 60-1.7(b)(1), and must be submitted by bidders and proposed subcontractors only in connection with contracts and subcontracts which are subject to the equal opportunity clause. Contracts and subcontracts which are exempt from the equal opportunity clause are set forth in 41 CFR 60-1.5 (Generally only contracts or subcontracts of $10,000 or under are exempt).

Proposed prime contractors and subcontractors who have participated in a previous contract or subcontract subject to the Executive Orders and have not filed the required reports should note that 41 CFR 60-1.7(b)(1) prevents the award of contracts and subcontracts unless such contractor submits a report covering the delinquent period or such other period specified by the U.S. Department of the Interior or by the Director, Office of Federal Contract Compliance, U.S. Department of Labor.

SF-100 (EEO-1) must be filed by;

(A) All private employers who are:

(1) Subject to Title VII of the Civil Rights Act of 1964 (as amended) with 100 or more employees.

(2) Subject to Title VII who has fewer than 100 employees, if the company is owned or affiliated with another company, or there is centralized ownership, control or management so that the group legally constitutes a single enterprise, and the entire enterprise employs a total of 100 or more employees.

(B) All federal contractors (private employers), who:

(1) Are not exempt as provided for by 41 CFR 60-1.5

(2) Have 50 or more employees, and

a. Are prime contractors or first-tier subcontractors, and have a contract, subcontract, or purchase order amounting to $50,000 or more; or

b. Serve as a depository of Government funds in any amount, or

c. Is a financial institution, which is an issuing, and paying agent for U.S. Savings Bonds and

Notes.

List of Proposed Subcontractors

Contractor must list all subcontracts involving labor at the site of construction, regardless of subcontract dollar amount or percentage of bid. If no subcontractors utilized for this project, please write none accross this page and submit with bid proposal.

PROJECT NAME AWARDING AGENCY

Location: ______________________________________________________ Project Number: ___________________________________________

SUB or Sub-Tier CONTRACTORS:

Name, Address, and Telephone Number

Employer

Identification

Number

Contractor

License

Number

Unique Entity

ID

Contract Amount

Estimated Start Date

Estimated Completion

Date TRADES TO BE USED

Signature Name and Title

Date Company Name

Company Employer Identification Number Company Contractor’s License Number

Company Unique Entity ID

Section 3 Business Concern Certification for

Contracting (Sample Form)

About this Tool

Description: Businesses seeking a preference in contracting on applicable Section 3 projects may qualify as a Section 3 business concern if they meet the following criteria: At least 51 percent of the business is owned and controlled by low- or very low-income persons, or at least 51 percent of the business is owned and controlled by current public housing residents or residents who currently live in Section 8-assisted housing, or over 75 percent of the labor hours performed for the business over the prior three-month period are performed by Section 3 workers.

This tool is designed to help grantees and their subrecipients, contractors, and subcontractors comply with the Section 3 requirements and achieve the Section 3 goals. It is intended to be a sample form to help grantees certify and track Section 3 business concerns seeking a preference in contracting.

How to Adapt this Document: This document is intended to be used as a reference tool to help grantees certify Section 3 business concerns and provide the appropriate records to support the business’ Section 3 status claims. Grantees are encouraged to adapt the form to fit the resources within their individual communities and to meet the needs of their program.

Source of Document: This document was developed by consultants affiliated with the consulting firm ICF.

Disclaimer: The following is a sample Section 3 Business Concern Certification form that PHAs or Community Development Offices may wish to use to begin developing their own form. They may work with their legal counsels to ensure it meets all local and state laws.

This resource will be part of a Section 3 Toolkit coming Fall of 2021. It will be hosted on the HUD Exchange at https://www.hudexchange.info/.

Updated as of: December 20, 2021 https://www.hudexchange.info/

Submit with Bid

Section 3 Business Concern

Certification for Contracting Instructions: Enter the following information and select the criteria that applies to certify your business’ Section 3 Business Concern status.

Business Information

Name of Business

Address of Business

Name of Business Owner

Phone Number of Business Owner

Email Address of Business Owner

Preferred Contact Information

☐ Same as above

Name of Preferred Contact

Phone Number of Preferred Contact

Type of Business (select from the following options):

☐Corporation ☐Partnership ☐Sole Proprietorship ☐Joint Venture

Select from ONE of the following three options below that applies:

☐ At least 51 percent of the business is owned and controlled by low- or very low-income persons.

☐ At least 51 percent of the business is owned and controlled by current public housing residents or residents who currently live in Section 8-assisted housing.

☐ Over 75 percent of the labor hours performed for the business over the prior three-month period are performed by Section 3 workers.

OR

☐ Written Commitment (Section 3 Economic Opportunity Plan), outline intentions to hire section 3 workers and/or subcontract with Section 3 Business Concerns.

(front side)

Business Concern Affirmation

I affirm that the above statements (on the front side of this form) are true, complete, and correct to the best of my knowledge and belief. I understand that businesses who misrepresent themselves as Section 3 business concerns and report false information to the City of Pasadena may have their contracts terminated as default and be barred from ongoing and future considerations for contracting opportunities. I hereby certify, under penalty of law, that the following information is correct to the best of my knowledge.

Print Name:

Signature: Date: __________

*Certification expires within six months of the date of signature

Information regarding Section 3 Business Concerns can be found at 24 CFR 75.5

FOR ADMINISTRATIVE USE ONLY

Is the business a Section 3 business concern based upon their certification?

□YES □NO

EMPLOYERS MUST RETAIN THIS FORM IN THEIR SECTION 3 COMPLIANCE FILE

FOR FIVE YEARS.

(backside) https://www.ecfr.gov/cgi-bin/text-idx?SID=569b66a547528bf6c5c47f75b825cb94&mc=true&node=pt24.1.75&rgn=div5#se24.1.75_15

The City of Pasadena

Section 3 Income Limits

Eligibility Guidelines

The worker’s income must be at or below the amount provided below for an individual household of 1 (regardless of actual household size).

Individual Income Limits for

Los Angeles County FY 2024

Income Limits Category

FY 2024

Income Limits

Extremely Low Income Limits (30%)

$26,500

Very Low Income Limits (50%)

$44,150

Low Income Limits (80%)

$70,650

See https://www.huduser.gov/portal/datasets/il.html for most recent income limits.

Section 3 Worker Definition:

• A low or very low-income resident (the worker’s income for the previous or annualized calendar year is below the income limit established by HUD); or

• Employed by a Section 3 business concern; or

• A YouthBuild participant.

Targeted Section 3 Worker Definition:

• Employed by a Section 3 business concern or

• Currently meets or when hired met at least one of the following categories as documented within the past five years:

• A resident of public housing; or

• A resident of other public housing projects or Section 8-assisted housing;

or

• A YouthBuild participant.

https://www.huduser.gov/portal/datasets/il.html

Notice of Section 3 Commitment Federal Compliance Form – Must be submitted with Bid and posted at Jobsite

TO: ________________________________________________________

(Name of Labor Union, Workers Representative, etc.

(Address)

Name of Business (Contractor): ___________________________________________________

Project Name: ______________________________ Project Number: ____________________

The Undersigned currently holds a contract with _____________________________________ involving Block Grant (CDBG) funds from the U. S. Department of Housing and Urban Development or a subcontract with a prime contractor holding such contract.

You are advised that under the provisions of the above contract or subcontract and in accordance with Section 3 of the Housing and Urban Development Act of 1968, the undersigned is obligated to the greatest extent feasible, to give opportunities for employment and training to lower income residence of the CDBG-assisted project area and to award contracts for work on the project to business concerns which are located in or are owned in substantial part by project area residence.

Regarding employment opportunities for Section 3, the minimum number and job titles are:

Minimum Number

Job Classification

Regarding job referrals, request that consideration be given, to the greatest extent feasible, to assignment of persons residing in the service area or neighborhood in which the project is located.

The anticipated date the work will begin is ___________ . For additional information, you may contact ________________________ , _____________________ at ( ) .

Contact Person’s Name Title

This notice is furnished to you pursuant to the provisions of the above contract or subcontract and Section 3 of the Housing and Urban Development Act of 1968. Copies of this notice will be posted by the undersigned in conspicuous places available to employees or applicants for employment.

_______________________________ By: __________________________________ (Print Name) (Signature)

(Date) (Title)

Section 3 Economic Opportunity Plan Federal Compliance Form – Must be submitted with Bid if Written Commitment Box is checked on Section 3 Business Concern Certification

1. Name and Address of Contractor: 2. Federal Identification: (Contract/Award No.) 3. Dollar Amount of Award:

4. Contact Person: 5. Phone: (include Area Code)

6. Reporting Period: 7. Date Report Submitted

8. Program Code: (Use a separate sheet for each Program Code)

Part I: Employment and Training Commitment

JOB

CLASSIFICATION

TOTAL PROJECT

LABOR HOURS

SECTION 3

LABOR HOURS

% of Total Project Labor Hours

Performed by Section 3 Workers

Professionals %

Technicians %

Office/Clerical %

Trade: %

Trade: %

Trade: %

Trade: %

Total: %

NAME OF

SECTION 3 BUSINESS CONCERN

SPECIFY

CONSTRUCTION CONTRACT

Part II: Contract Award Commitment to Section 3 Businesses (Subcontractors)

CONTRACT

AMOUNT

TOTAL $

Percentage of the total dollar amount to be awarded to Section 3 Business

Concerns: %

Program Codes

1. Flexible Subsidy 2. Section 202/811 3. Public/Indian Housing Development, Operation and Modernization 4. Homeless Assistance 5. HOME

6. HOME - State Administered 7. CDBG – Entitlement 8. CDBG - State Administered 9. Other CD Programs 10. Other Housing Programs

Section 3 Housing and Community Development Employer Certification Form

U.S. Department of Housing and Urban Development

Office of Field Policy and Management

HUD FORM 4736A

OMB Approval Number 2501-0041

(Exp. 04/30/2025)

(In compliance with Section 3 of the HUD Act of 1968 and 24 CFR Part 75)

Public reporting for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.

Section 3 of the Housing and Urban Development Act of 1968, as amended by the Housing and Community Development Act of 1992 (Section 3), and 12 U.S.C. § 1701u ensure that employment and other economic opportunities generated by Federal financial assistance for housing and community development programs are, to the greatest extent feasible, directed toward low- and very low-income persons, particularly those who receive government assistance for housing.

The regulations are found at 24 CFR Part 75. This collection of information is required in order to ensure that a worker can be certified as an eligible Section 3 worker as outlined in 24 C.F.R. § 75.31. The in-formation will be used by the Department to ensure compliance with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31, to assess the results of the Department's efforts to meet the statutory objectives of Section 3, to prepare reports to Congress, and by recipients to ensure they are complying with their recordkeeping requirements found in the regulation, and as a self-monitoring tool.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to Anna P. Guido, Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. 2501-0041. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number. No assurances of confidentiality are provided for this information collection.

The purpose of this form is to comply with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31. To qualify as a Section 3 worker, the United States legal resident’s annual income must not exceed the HUD income limits for the year before the worker was hired, or the individual’s current income annualized on a full-time basis for the year must be below the HUD income limit.

Additionally, an individual can qualify as a Section 3 worker and Targeted Section 3 worker, if an employee of a Section 3 Business Concern. To qualify as a Targeted Section 3 worker, an employer can confirm that the employee lives within the service area or neighborhood of the project.

Please provide the following information about the business/employer:

Name of Business: __________________________________________________________________________________

Street Address City State Zip

Phone #: ________________________ Email: _________________________________________________

Please Provide the following information about the worker/employee:

Printed Name of Worker:

Street Address (Not a PO Box) Apt# City State Zip

Phone #: Email:

Please indicate which of the following is true for the worker listed above: (Select all that apply)

____ Worker’s income from your employment is below the income limit based on a calculation of what the worker’s wage rate would translate to if annualized on a full-time basis*

____ Worker is employed by a Section 3 Business Concern (Select if your business qualifies as a Section 3 Business Concern)

____ Worker’s residence is within the service area or neighborhood of the project

Income limit

$70,650

*Currently or at the time of hire if hired within the past 5 years.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct and certifies that the worker identified above meets the definition of a Section 3 worker. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)

Signature Date

Section 3 Worker Self- Certification-Housing and Community Development

U.S. Department of Housing and Urban Development

Office of Field Policy and Management

HUD FORM 4736C

OMB Approval Number 2501-0041

(Exp. 04/30/2025)

(In compliance with Section 3 of the HUD Act of 1968 and 24 CFR Part 75)

Public reporting for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.

Section 3 of the Housing and Urban Development Act of 1968, as amended by the Housing and Community Development Act of 1992 (Section 3), and 12 U.S.C. § 1701u ensure that employment and other economic opportunities generated by Federal financial assistance for housing and community development programs are, to the greatest extent feasible, directed toward low- and very low-income persons, particularly those who receive government assistance for housing. The regulations are found at 24 CFR Part 75. This collection of information is required in order to ensure that a worker can be certified as an eligible Section 3 worker as outlined in 24 C.F.R. § 75.31. The in-formation will be used by the Department to ensure compliance with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31, to assess the results of the Department's efforts to meet the statutory objectives of Section 3, to prepare reports to Congress, and by recipients to ensure they are complying with their recordkeeping requirements found in the regulation, and as a self-monitoring tool.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to Anna P. Guido, Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. 2501-0041. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number. No assurances of confidentiality are provided for this information collection.

The purpose of this form is to comply with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31. To qualify as a Section 3 worker, any United States legal resident’s annual income must not exceed the HUD income limits for the year before the worker was hired, or the individual’s current income annualized on a full-time basis for the year must be below the HUD income limit. Additionally, an individual can qualify as a Section 3 worker if they are a YouthBuild participant or employee of a Section 3 Business concern.

Printed Name:

Street Address (Not a PO Box) Apt# City State Zip

Phone #: Email:

To qualify as a Section 3 Worker, you must meet one of the following requirements OR have your employer certify that you are employed by a Section 3 Business concern:

• Income for the previous calendar year is below the income limit*

• A participant in a means-tested program such as public housing or Section

8-assisted housing

• A YouthBuild Participant*

Income limit

$70,650

*Currently or at the time of hire if hired within the past 5 years

I meet at least one of the requirements in the box above and therefore qualify to be counted as a Section 3 Worker under 24 CFR § 75.

If applicable, please indicate which requirement you meet to be considered a Targeted Section 3 worker in the box below. If you select “Living within the service area or neighborhood of the project,” that selection will have to be confirmed by your employer. If you do not meet any of these requirements or do not know if you meet any of the requirements listed below, you may leave this section blank.

___ Living within the service area or neighborhood of the project (requires employer confirmation)*

___ YouthBuild participant*

*Currently or at the time of hire if hired within the past 5 years

In addition to qualifying as a Section 3 Worker, I meet at least one of the requirements in the box above and therefore qualify to be counted as a Targeted Section 3 Worker under 75 CFR § 75.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct and certifies that the worker identified above meets the definition of a Section 3 worker. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)

Signature Date

FRINGE BENEFIT STATEMENT

CONTRACTOR OR SUBCONTRACTOR (Please Print) ICONTRACT NUMBER | DATE

I I

DEPARTMENT OF INDUSTRIAL REGISTRATION

NUMBER

CONTRACTORS STATE LICENSE

BOARD NUMBER PROJECT NAME

Labor Compliance uses the following fringe benefits information (shown or referenced on wage rate determinations) paid to or on behalf of employees in various crafts or classifications to check payroll or apply to force account work on the above contract.

COMPLETE AND SUBMIT THIS FORM WITH THE FIRST CERTIFIED PAYROLL OR WHEN THERE HAVE BEEN CHANGES.

Classification Fringe Benefit Hourly Amount Name, Address, and Telephone # of Plan/Fund Program

Effective Date

Subsistence and/or Travel Pay

Vacation $ ___________________

Health and Welfare

Pension $ ___________________

Apprentice or Training Fees

Other $ ___________________

Classification Fringe Benefit Hourly Amount

Effective Date

Subsistence and/or Travel Pay

Classification Fringe Benefit Hourly Amount

Effective Date

Subsistence and/or Travel Pay

I certify under penalty of perjury that fringe benefits are paid to the approved Plans, Funds, or Programs listed above.

NAME AND TITLE (Please Print)

SIGNATURE BUSINESS TELEPHONE NUMBER :

Vacation $ ___________________

Health and Welfare

Pension $ ___________________

Apprentice or Training Fees

Other $ ___________________

Vacation $ ___________________

Health and Welfare

Pension $ ___________________

Apprentice or Training Fees

Other $ ___________________

Name, Address, and Telephone # of Plan/Fund Program

Name, Address, and Telephone # of Plan/Fund Program

OR: (Check if applicable)

I certify that I do not make payments to approved frienge benefit plans, funds, or programs.

Also, the willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution (see Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code).

(Contractor or subcontractor)

(Contractor or subcontractor)

(Project)

STATEMENT OF COMPLIANCE

Date:

do hereby state:

(Name of signatory party) (Title)

(1) That I pay or supervise the payment of the persons reported on the Certified Payroll Report by on the , that during the payroll period commencing on the day of and ending the day of 20 , all persons working on said project have been paid the full weekly sums earned, that no rebates have been or will be made either directly or indirectly to, or on behalf of, said from the full weekly sums earned by any person and that no deductions have been made either directly or indirectly from the full sums earned by any person, other than permissible deductions, as described below:

(2) That any payrolls or listings or otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency.

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

(c) EXCEPTIONS

EXCEPTION (CRAFT) EXPLANATION

Remarks:

NAME AND TITLE SIGNATURE

In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll or listings payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below.

Each Laborer or mechanic listed in the above referenced payroll or listings has been paid as indicated on the payroll or listings an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below:

U.S. Department of Labor PAYROLL (For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm) Wage and Hour Division

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.

NAME OF CONTRACTOR OR SUBCONTRACTOR ADDRESS OMB No.:1235-0008 Expires: 07/31/2024

PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO.

(1) (2) (3) (4) DAY AND DATE (5) (6) (7) (9)

(8)

DEDUCTIONS

O

O

O

O

O

O

O

O

NAME AND INDIVIDUAL IDENTIFYING NUMBER

(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY

NUMBER) OF WORKER N

O

. O F

W

IT

H H

O

LD

iN G

E

XE

M

P

TI

O N

S

WORK

CLASSIFICATION

O T.

O R

S T.

HOURS WORKED EACH DAY

TOTAL

HOURS

RATE

OF PAY

GROSS

AMOUNT

EARNED FICA

WITH-

HOLDING

TAX OTHER

TOTAL

DEDUCTIONS

NET

WAGES

PAID

FOR WEEK

S

S

S

S

S

S

S

S

Rev. Dec. 2008

Rev. Dec. 2008

While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency contracting for or financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper Davis-Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.

Public Burden Statement

We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W.

Washington, D.C. 20210

(over) nthai nthai nthai

Date

I, (Name of Signatory Party) (Title) do hereby state:

(1) That I pay or supervise the payment of the persons employed by on the (Contractor or Subcontractor)

; that during the payroll period commencing on the (Building or Work) day of , , and ending the day of , , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described below:

(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

− in addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in section 4(c) below.

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

− Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in section 4(c) below.

(c) EXCEPTIONS

REMARKS:

EXCEPTION (CRAFT) EXPLANATION

NAME AND TITLE SIGNATURE

THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 3729 OF

TITLE 31 OF THE UNITED STATES CODE.

nthai nthai

Certification of Understanding and Authorization

Project Name:

Contracting Agency:

This is to certify that the principals and the authorized payroll officer, below, have read received a copy of the Federal Labor Standard Provisions (HUD-4010) and a copy of the Contractor's Guide to Prevailing Wage Requirements for Federally-Assisted Construction Projects, and that they understand the labor standard clasues pertaining to the above listed project.

The following person(s) is designated at the payroll officer for the undersigned and is authorized to sign the Statement of Compliance that will accompany each weekly certified payroll report for the contractor listed below during the duration of this project:

Name Designated Payroll Officer (Print) Designated Payroll Officer (Signature)

Authorized Signature

Contractor Business Name

(Title)

License Number

(Date)

Name of Person Authorized to Sign (print)

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

REPORT OF ADDITIONAL CLASSIFICATION AND RATE

HUD FORM 4230A

OMB Approval Number 2501-0011

(Exp. 8/31/2022)

1. FROM (name and address of requesting agency) 2. PROJECT NAME AND NUMBER

3. LOCATION OF PROJECT (City, County and State)

4. BRIEF DESCRIPTION OF PROJECT 5. CHARACTER OF CONSTRUCTION

Building

Heavy

Highway

Residential

Other (specify)

6. WAGE DECISION NO. (include modification number, if any)

COPY ATTACHED

DATE of WAGE DECISION: 7. WAGE DECISION EFFECTIVE

DATE (LOCK-IN):

8. WORK CLASSIFICATION(S) HOURLY WAGE RATES

BASIC WAGE FRINGE BENEFIT(S) (if any)

9. PRIME CONTRACTOR (name, address) 9a.

Agree

Disagree

10. SUBCONTRACTOR/EMPLOYER, IF APPLICABLE

(name, address)

9b. SIGNATURE DATE

Check All That Apply:

The work to be performed by the additional classification(s) is not performed by a classification in the applicable wage decision.

The proposed classification is utilized in the area by the construction industry.

The proposed wage rate(s), including any bona fide fringe benefits, bears a reasonable relationship to the wage rates contained in the wage decision.

The interested parties, including the employees or their authorized representatives, agree on the classification(s) and wage rate(s).

Supporting documentation attached, including applicable wage decision.

Check One:

Approved, meets all criteria. DOL confirmation requested.

One or more classifications fail to meet all criteria. DOL decision requested.

FOR HUD USE ONLY

LR2000:

Agency Representative (Typed name and signature)

Date Log in:

Log out:

Phone Number

HUD-4230A (8-19) PREVIOUS EDITION IS OBSOLETE

Report of Additional Classification and Wage Rate

U.S. Department of Housing and Urban Development Davis-Bacon & Labor Standards

OMB Approval No. 2501-0011 (Exp. 08/31/2022)

Instructions for HUD-4230A (8-19) PREVIOUS EDITION IS OBSOLETE

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. The information is considered non-sensitive and does not require special protection. This information is required to obtain benefits.

This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

Employers engaged on HUD-assisted construction projects subject to Davis-Bacon wage requirements must pay no less than the wages determined to be prevailing by the Secretary of Labor to all laborers and mechanics engaged on the construction work. On occasion, the applicable Davis-Bacon wage decision does not contain all of the work classifications and wage rates needed to complete the construction work.

This information collection facilitates the addition of needed work classifications and wage rates for the construction work involved. This form is used by HUD and local agencies administering HUD programs to report employer request(s) for additional classification and wage rates so that an appropriate wage rate can be approved by the Department of Labor for the construction work. This information collection is required by Department of Labor regulations at 29 CFR 5.5. While no assurances of confidentiality are pledged to respondents, HUD generally discloses these data only in response to a Freedom of Information request.

Instructions for Local Contracting Agencies

General:

Contractors/Employers: Do not need to complete this form. Submit a written, signed request to the responsible contracting agency naming the work classifications and the wage rates, including any fringe benefits, that are proposed.

Local Agency Staff: Complete items 1 through 10. Submit a copy of this form to directly to U.S. DOL with a copy of the applicable Davis-Bacon wage decision and the written request from the employer naming the work classifications and wage rates that are proposed. (The employer’s request must be made in writing and must be signed.) DOL typically responds within 30 days. If you need help in filling out this form, you are welcome to contact the DBLS regional office nearest to you, found here

- https://www.hud.gov/program_offices/davis_bacon_and_labor_standards/laborrelstf.

1. Enter the name and address of the office submitting the report and to which the DOL reply should be sent.

2. Enter the name and number of the project or contract involved.

3. Enter the location of the project involved: city, county and state.

4. Describe the construction involved, e.g., new construction or rehabilitation, number and type of buildings, number of stories, number of units (as applicable). For example, New construction: 3 – 4-story buildings; 120 units.

5. Enter the character of construction as defined by DOL for Davis-Bacon prevailing wage rate purposes.

6. Enter the number and date of the Davis-Bacon wage decision applicable to the construction work. Include the number of the wage decision modifications (if any) applicable to the work and its date.

7. Enter the effective date (lock-in date) of the wage decision for the project. (See DOL regulations at 29 CFR 1.6.)

8. Enter the work classifications and corresponding hourly basic wage rates and fringe benefit rates (if any) requested.

9. Enter Prime Contractor name and address.

9a. Prime Contractor marks whether agree or disagree with the request.

9b. Signature of Prime Contractor and date signed.

10. If the requesting employer is not the prime contractor, enter the name and address of the subcontractor/employer making the request.

Remainder of Form:

Evaluate the employer’s request against the criteria for approval (see DOL Regulations, 29 CFR Part 5, and related contract labor standards provisions). The criteria are reflected in “checklist” form to ensure that each factor is considered and to ensure that supporting documentation, including a copy of the applicable wage decision, is attached. Check the box next to each criterion that is met; do not check the box next to any criterion that is not met.

If the request meets all criteria, check the appropriate box, enter the name and telephone number of the agency representative, sign and date the form. Submit one copy of the completed form to the DOL with a copy of the applicable Davis-Bacon wage decision and the written request from the employer involved.

If the request fails to pass all criteria, check the appropriate box, enter agency contact information, and sign and date the form.

Submit one copy of the completed form to the DOL with a copy of the applicable Davis-Bacon wage decision, the written request from the employer involved, and a cover letter explaining how the employer’s request failed to meet one or more of the criteria.

Submission of Form:

Completed form(s) and supporting documents shall be sent to: Branch of Construction Wage Determinations, U.S. Department of Labor, 200 Constitution Avenue, NW, Room S-3014, Washington, DC 20210 or emailed to whd-cbaconformance_incoming@dol.gov.

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