Sample_E-Verify_Form.pdf
PDF 591 KB Posted
- Attached to
- Physician Services
- Solicitation number
- 2022-RFP-082
- Issued by
- Cook County, Washington
About this file
The document is an E-Verify Declaration form issued by Pierce County, Washington, requiring contractors to enroll in the E-Verify program for county contracts exceeding specific monetary thresholds. The form applies to public works contracts over $100,000 and other county contracts over $25,000 with a duration greater than 120 days. Contractors must enroll in the E-Verify system, provide certification with their bid submittal, and verify enrollment of all applicable subcontractors. Pierce County reserves the right to request a Memorandum of Understanding from the Department of Homeland Security at any time during the project, with failure to provide documentation potentially resulting in project suspension.
The form requires contractors to declare under penalty of perjury that they are currently enrolled in the E-Verify system implemented on March 1, 2010, and will continue using it throughout the project's duration. Contractors must certify their authorization to sign the declaration and acknowledge Pierce County's right to request verification documentation within 10 days. The E-Verify Program is a web-based application accessible at www.dhs.gov/everify, designed to confirm the employment eligibility of workers. The document is a sample form with blank spaces for firm name, contract number, date, signature, printed name, and title, indicating it is a template for contractors to complete when bidding on Pierce County contracts.
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Other files
| File | Type | Posted |
|---|---|---|
| Physician_Services_(Addendum_#8_Revision).pdf | ||
| sample_PSA.pdf |
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Text version
E-VERIFY DECLARATION
Firm Name: __________________________________________________
Contract No.____________________________
Pierce County requires that, as a condition for the award of any County contract for public works in excess of $100,000.00 or any other County contract in excess of $25,000.00, and the duration of the contract is greater than 120 days, the business entity or contractor shall enroll in the E Verify program, or its successor, and thereafter shall provide the County documentation affirming its enrollment and participation in the program. The requirement extends to every subcontractor meeting the same criteria. The Prime Contractor must provide certification of enrollment with bid submittal. The Prime Contractor is responsible for verification of every applicable subcontractor.
Pierce County reserves the right to require a copy of a Memorandum of Understanding between the Prime or any Subcontractor and Department of Homeland Security upon request at any time during the project verifying the contractor’s enrollment. Failure to provide this document could result in suspension of the project.
The Federal E-Verify Program is a web-based application that can be accessed at:
www.dhs.gov/everify.
The undersigned declares, under penalty of perjury under the laws of Washington that:
1. That the above named firm is currently enrolled in and using the E-Verify system implemented on March 1, 2010 as outlined in PCC 2.106.022 and will continue to use the E-Verify system for so long as work is being performed on the above named project.
2. I certify that I am duly authorized to sign this declaration on behalf of the above named bidder/proposer.
3. I acknowledge that Pierce County reserves the right to require a copy of the Memorandum of Understanding between the contractor listed above and the Department of Homeland Security certifying enrollment in the E-Verify program at any time. Failure to provide the required Memorandum of Understanding within 10 days of request could lead to suspension of this contract.
Dated at Washington this day of , 20
Signature
Printed Name
Title
END OF FORM
SAMPLE
http://www.dhs.gov/everify
File details come from the government source that posted it. Updated .