Instructions for "Statement of Compliance Form" - Minnesota

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Minnesota Department of Transportation
Statement of Compliance Form Guide
Each contractor that performed work under a contract that is funded in whole or in part with
federal and/or state funds must complete the Mn/DOT Statement of Compliance Form. The
form should be attached to the payroll and submitted to the Project Engineer. Incomplete forms
will be returned to the contractor.
Must indicate the
number of workers
performing work on
the project.
Check One Only
Minnesota Department of Transportation
Statement of Compliance Form Guide
Each contractor that performed work under a contract that is funded in whole or in part with
federal and/or state funds must complete the Mn/DOT Statement of Compliance Form. The
form should be attached to the payroll and submitted to the Project Engineer. Incomplete forms
will be returned to the contractor.
Must indicate the
number of workers
performing work on
the project.
Check One Only
 
If 4(a) is checked, enter the
name(s) of the person(s) who
do not receive fringe benefit(s)
reported in 4(d) (e.g. non-
union, seasonal worker,
worker has not worked for the
company long enough, etc.).
NOTE: If 4(b) is checked or
if workers are listed in 4(c), the
workers must receive the total
contract rate, which is
considered taxable income, as
cash on their paycheck.
If each worker receives the same
fringe benefit rate, place the title
of the plan here.
OR
If each worker has a different
fringe benefit rate, place their
names here with the respective
amounts.
OR
A separate sheet that contains
the breakdown of each worker’s
benefits can be attached to this
form. Make note of the
attachment by writing “See
Attached Sheet” here.
Specify the dollar amount
contributed per hour as a
fringe benefit. Failure to do
so will result in the rejection
of the form.
Fill out the complete name
and address of the fringe
benefit plan.
Specify the benefit
account number, contact
person and telephone
number.
Print clearly the name
and title of the
representative signing the
payroll.
This form must be signed
or it will not be accepted.
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