Sedgwick - Advertisement - Appendix E - Contract Wage Compliance Form.pdf

Colorado Department of Transportation

CONTRACTOR WAGE COMPLIANCE STATEMENT

FOR STATE FUNDED PUBLIC PROJECTS

Project Location:

Project Code:

Project Number:

Contractors/subcontractors

Completion of the payroll supervisor appointment and perjury statement is required by the State of Colorado and is included on the back of this form. Contractors/subcontractors are required to pay weekly. Prime contractors are required to submit this form, each month with the approved pay application form to the CDOT Construction manager. The prime contractor is responsible for subcontractor payroll submittal and compliance; by submittal of subcontractor payrolls, the prime contractor certifies that they have reviewed the submittal for compliance.

Payroll periodPayroll numberContractor/subcontractor name to

Fringe benefit information:

Name(s)/addresses of fringe benefit administrator(s):

Contact person and phone number(s):

Contributions are made in cash or to the plans, funds or programs described below at least quarterly. There are no past due deposits. List the value of the fringe amount as the dollar amount per hour. Documentation of calculations used to determine hourly rates shall be available upon request. Please attach additional information as necessary if fringe contributions vary by employee.

cash ______ pension _______ health insurance ______ vacation _______ dental insurance ______ holiday _______ life insurance ______ other (describe) _______

All on-the-job trainees (OJTs) employed in the above period are registered in and paid according to a bona fide training program approved by the Colorado Department of Transportation and the Federal Highway Administration. Each trainee has also been approved for work on this contract.

I declare under penalty of perjury in the second degree, and any other State or Federal laws that the statements made in this document are true and complete to the best of my knowledge.

Contractor/subcontractor payroll supervisor or signatory party Date

Page 1 of 2 (over) CDOT Form #119 9/21

Date (Name of signatory party)

I, (Title) do hereby state:

(1) That I pay or supervise the payment of the persons employed by (Contractor or Subcontractor) (Building or work) on the that during the payroll period commencing on the 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

(Contractor or Subcontractor) day of and ending the Month Year day of Month Year from the full 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 CFR 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. 276c), 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 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 FRINGES 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 FRINGES 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

Page 2 of 2 CDOT Form #119 9/21

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.

Name and Title Signature

Remarks

Exception (craft) Explanation