Form PW-4 "Affidavit of Compliance With the Prevailing Wage Law" - Missouri

What Is Form PW-4?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PW-4 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form PW-4 "Affidavit of Compliance With the Prevailing Wage Law" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AFFIDAVIT
COMPLIANCE WITH THE PREVAILING WAGE LAW
I, ____________________________________, upon being duly sworn upon my oath state that: (1) I am the
(Name)
______________________________ of __________________________________________; (2) all requirements of
(Title)
(Name of Company)
§§ 290.210 to 290.340, RSMo, pertaining to the payment of wages to workers employed on public works projects
have been fully satisfied with regard to this company’s work on _________________________________________;
(Name of Project)
(3) I have reviewed and am familiar with the prevailing wage rules in 8 CSR 30-3.010 to 8 CSR 30-3.060; (4) based
upon my knowledge of these rules, including the occupational titles set out in 8 CSR 30-3.060, I have completed full
and accurate records clearly indicating (a) the names, occupations, and crafts of every worker employed by this
company in connection with this project together with an accurate record of the number of hours worked by each
worker and the actual wages paid for each class or type of work performed, (b) the payroll deductions that have been
made for each worker, and (c) the amounts paid to provide fringe benefits, if any, for each worker; (5) the amounts
paid to provide fringe benefits, if any, were irrevocably made to a fund, plan, or program on behalf of the workers;
(6) these payroll records are kept and have been provided for inspection to the authorized representative of the
contracting public body and will be available, as often as may be necessary, to such body and the Missouri
Department of Labor and Industrial Relations; (7) such records shall not be destroyed or removed from the state for
one year following the completion of this company’s work on this project; and (8) there has been no exception to the
full and complete compliance with the provisions and requirements of Annual Wage Order No. _____ Section
______ issued by the Missouri Division of Labor Standards and applicable to this project located in
___________________ County, Missouri, and completed on the ____ day of __________________, _______.
The matters stated herein are true to the best of my information, knowledge, and belief. I acknowledge that
the falsification of any information set out above may subject me to criminal prosecution pursuant to §§290.340,
570.090, 575.040, 575.050, or 575.060, RSMo.
____________________________________________
Signature
Subscribed and sworn to me this ____ day of _________________, ________.
My commission expires _______________________________, ________.
______________________________________
Notary Public
____________________________________________
Receipt by Authorized Public Representative
Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program.
PW-4 (07-14) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
AFFIDAVIT
COMPLIANCE WITH THE PREVAILING WAGE LAW
I, ____________________________________, upon being duly sworn upon my oath state that: (1) I am the
(Name)
______________________________ of __________________________________________; (2) all requirements of
(Title)
(Name of Company)
§§ 290.210 to 290.340, RSMo, pertaining to the payment of wages to workers employed on public works projects
have been fully satisfied with regard to this company’s work on _________________________________________;
(Name of Project)
(3) I have reviewed and am familiar with the prevailing wage rules in 8 CSR 30-3.010 to 8 CSR 30-3.060; (4) based
upon my knowledge of these rules, including the occupational titles set out in 8 CSR 30-3.060, I have completed full
and accurate records clearly indicating (a) the names, occupations, and crafts of every worker employed by this
company in connection with this project together with an accurate record of the number of hours worked by each
worker and the actual wages paid for each class or type of work performed, (b) the payroll deductions that have been
made for each worker, and (c) the amounts paid to provide fringe benefits, if any, for each worker; (5) the amounts
paid to provide fringe benefits, if any, were irrevocably made to a fund, plan, or program on behalf of the workers;
(6) these payroll records are kept and have been provided for inspection to the authorized representative of the
contracting public body and will be available, as often as may be necessary, to such body and the Missouri
Department of Labor and Industrial Relations; (7) such records shall not be destroyed or removed from the state for
one year following the completion of this company’s work on this project; and (8) there has been no exception to the
full and complete compliance with the provisions and requirements of Annual Wage Order No. _____ Section
______ issued by the Missouri Division of Labor Standards and applicable to this project located in
___________________ County, Missouri, and completed on the ____ day of __________________, _______.
The matters stated herein are true to the best of my information, knowledge, and belief. I acknowledge that
the falsification of any information set out above may subject me to criminal prosecution pursuant to §§290.340,
570.090, 575.040, 575.050, or 575.060, RSMo.
____________________________________________
Signature
Subscribed and sworn to me this ____ day of _________________, ________.
My commission expires _______________________________, ________.
______________________________________
Notary Public
____________________________________________
Receipt by Authorized Public Representative
Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program.
PW-4 (07-14) AI