Statement_of_Intent_To_Pay_Prevailing_Wages.pdf

(Revised 08/22/2013)

STATEMENT OF INTENT TO PAY PREVAILING WAGES

To Be Completed Before Construction Starts

All FIELDS ARE REQUIRED

FORM MUST BE SENT TO THE CONTRACTING AGENCY WITHIN 3 DAY OF THE AWARD

General Contractor Information Company Name:

Address:

City : State: Zip:

Phone: Fax: E-Mail:

Estimated Start Date: State Wage Decision Number:

Project Title:

Project Physical Address:

Total Contract Amount: Estimated Completion Date:

Print Name:

General Contractor Signature:

Sub Contractor Information Sub Contract Amount:

Start date on this project:

Company Name:

Address:

City: State: Zip:

Phone: Fax: E-Mail:

Sub Contractor Signature:

2nd, 3rd, etc. Tier Sub-Contractor Information Contract Amount:

Start date 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 will be 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 1978).

Contractor’s Signature Date

(Revised 08/22/2013)

INSTRUCTIONS FOR COMPLETING STATEMENT OF INTENT TO PAY PREVAILING WAGES

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 estimated start & completion dates of project.

6. Enter general contractor’s contract amount.

7. All Statements 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 contract amount.

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

2ND TIER SUB CONTRACTOR

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

2. Enter sub contractor information; subcontractor signature not needed.

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

4. Enter 2nd tier contractors contract amount.

3RD TIER AND HIGHER CONTRACTOR

1. Attach a copy of this completed form & list the 3rd tier contractor information under the 2nd tier