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CITY OF MIDDLETOWN Department of Planning Conservation Development Community Development Division CDBG Contractor Information Form Statement of Intent to Pay Prevailing Wage Organization Project Project Type Public Facility Construction Housing Rehabilitation Infrastructure Demolition Business Other Contractor Information Company Name Tax ID Number Address City State ZIP Type of Firm Low-income Owned Section 3 Firm Minority Owned Firm Women Owned Firm Other Workers Information Number of owners that own at least 30 of the company who will perform work on this project Number of non-owners who will perform work on this project List of workers owners and non-owners Rate of Pay F. Ben. Craft/trade/occupation Num. of Workers Hourly If necessary continue on another sheet. Prevailing Wage and Weekly Payrolls Certification I hereby certify that the above information is correct and that all workers I employ on this Public Works Project were paid no less than the Prevailing Wage rate s as determined by the Federal Department of Labor. I understand that contractors that violate to fines and or debarment and will be required to pay back any back wages due to workers. I hereby certify that weekly certified payrolls will be submitted along with any request for payment. Signature Name Date Certified Payroll Exemptions Declaration I am a volunteer and I will not receive compensation for the labor contributed to this project Project involves demolition with no reconstruction of similar-use or different-use structure. Prevailing Wage and Weekly Payrolls Certification I hereby certify that the above information is correct and that all workers I employ on this Public Works Project were paid no less than the Prevailing Wage rate s as determined by the Federal Department of Labor. I understand that contractors that violate to fines and or debarment and will be required to pay back any back wages due to workers. I understand that contractors that violate to fines and or debarment and will be required to pay back any back wages due to workers. I hereby certify that weekly certified payrolls will be submitted along with any request for payment. I hereby certify that weekly certified payrolls will be submitted along with any request for payment. Signature Name Date Certified Payroll Exemptions Declaration I am a volunteer and I will not receive compensation for the labor contributed to this project Project involves demolition with no reconstruction of similar-use or different-use structure. Prevailing Wage and Weekly Payrolls Certification I hereby certify that the above information is correct and that all workers I employ on this Public Works Project were paid no less than the Prevailing Wage rate s as determined by the Federal Department of Labor. I understand that contractors that violate to fines and or debarment and will be required to pay back any back wages due to workers. I hereby certify that weekly certified payrolls will be submitted along with any request for payment.

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