ITB202608_CDBG_Infrastructure_Improvement_Project__Exhibit_S.pdf

Rev. January 2025 OMB No.: 1235-0008 Expires: 01/31/2028

U.S. Department of Labor Wage and Hour Division

Davis-Bacon and Related Acts Weekly Certified Payroll Form (For Contractor’s Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm)

Unless otherwise noted, the information requested is specific to the named project below.

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

SUBMISSION OF FINAL DBRA CERTIFIED PAYROLL FORM PRIME CONTRACTOR SUBCONTRACTOR

PROJECT NAME PROJECT NO. or CONTRACT NO. CERTIFIED PAYROLL NO. PRIME CONTRACTOR’S/SUBCONTRACTOR’S BUSINESS NAME

PROJECT LOCATION WAGE DETERMINATION NO. WEEK ENDING DATE PRIME CONTRACTOR’S/SUBCONTRACTOR’S BUSINESS ADDRESS

(1A) (1B) (1C) (1D) (1E) (2) (3) (4) (5) (6A) (6B) (6C) (7A) (7B) (8) (9)

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While use of Form WH-347 itself is optional, covered contractors and subcontractors performing work on Federal or federally assisted construction contracts are required by the DBRA regulations and the contract clauses to submit payroll information on a weekly basis. The Copeland Act (40 U.S.C. § 3145) requires contractors and subcontractors performing work on Federal or federally financed construction contracts to, on a weekly basis, “furnish a statement on the wages paid each employee during the prior week.” U.S. Department of Labor (DOL) Regulations at 29 C.F.R. § 5.5(a)(3)(ii) require contractors and subcontractors to submit weekly certified payrolls to the appropriate Federal agency if the agency is a party to the contract (or, if the agency is not such a party, to the applicant, sponsor, owner, or other entity, as the case may be, that maintains such records, for transmission to the Federal agency). Each certified payroll must be accompanied by a signed “Statement of Compliance” (e.g., page 2 of the WH-347 or another document with identical wording) indicating that the certified payrolls are accurate and complete, and that each laborer or mechanic has been paid not less than the required Davis-Bacon prevailing wage rate(s) (including any fringe benefits) for the work performed. DOL and contracting agencies receiving this information review the information to determine whether workers have received legally required wages and fringe benefits.

Public Burden Statement We estimate that it 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) http://www.dol.gov/whd/forms/wh347instr.htm

PROJECT NAME PROJECT NO. or CONTRACT NO. PAYROLL NO. PRIME CONTRACTOR’S/SUBCONTRACTOR’S BUSINESS NAME

PROJECT LOCATION WEEK ENDING DATE CERTIFYING OFFICIAL’s NAME AND TITLE

I paid or supervised the payment of the laborers or mechanics working on the above project during the stated time period. I certify the following:

The payroll information submitted with this statement is correct and complete for the above project during the above period, and the wage and fringe benefit rates paid to the workers, including credit taken for the reasonably anticipated costs of a bona fide fringe benefit plan, fund or program, are not less than the applicable wage and fringe benefits rates for the classification(s) of work actually performed, as specified in the wage determination(s) incorporated into the contract.

All regular payrolls and all other basic records that the contractor is required to maintain for this payroll period are complete and accurate and will be made available upon request from the agency or the Department of Labor.

The classifications reported for each laborer or mechanic are the classification(s) of work that each worker actually performed.

Any workers paid as apprentices during the above period are duly registered in a bona fide apprenticeship program registered with the Office of Apprenticeship, Employment and Training Administration, United States Department of Labor (“OA”), or a State Apprenticeship Agency (“SAA”) recognized by Department of Labor. I have verified the registered apprenticeship program information provided below as accurate and applicable to any apprentices identified on page 1 of this form.

APPRENTICESHIP PROGRAM NAME REGISTERED NAME OF LABOR CLASSIFICATION

OA SAA

OA SAA

OA SAA

Fringe benefits have been paid in cash and/or to bona fide fringe benefit plans, funds, or programs. Where the contractor is claiming an hourly credit for their contributions to or reasonably anticipated costs of a bona fide fringe benefit plan, fund, or program, provide plan information and the hourly credit claimed for each worker listed on the previous page of this form.

HOURLY CREDIT FOR FRINGE BENEFITS

If an amount is listed in (6B) on the first page of this certified payroll form, enter the hourly credit claimed under each plan name, type and number for each worker and check whether the plan is funded or unfunded.

NAME OF WORKER

FB NAME FB NAME FB NAME FB NAME FB NAME FB NAME

TOTAL

HOURLY

CREDIT

FB TYPE FB TYPE FB TYPE FB TYPE FB TYPE FB TYPE

PLAN NO. PLAN NO. PLAN NO. PLAN NO. PLAN NO. PLAN NO.

Funded Unfunded Funded Unfunded Funded Unfunded Funded Unfunded Funded Unfunded Funded Unfunded

Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hourly Credit $ Hrly Credit $ $

All workers on the project have been paid the full weekly wages earned, and no rebates or deductions have been or will be made either directly or indirectly, other than permissible deductions as defined in 29 CFR part 3.

ADDITIONAL REMARKS

SIGNATURE OF CERTIFYING OFFICIAL DATE TELEPHONE NUMBER EMAIL ADDRESS

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), AS WELL AS DEBARMENT FROM FUTURE FEDERAL AND FEDERALLY-ASSISTED CONTRACTS. INFORMATION REPORTED IN CERTIFIED PAYROLLS MAY BE SUBJECT TO DISCLOSURE IN RESPONSE TO A FREEDOM OF INFORMATION ACT REQUEST.