Steven Bellone Frank Nardelli
Suffolk County Executive Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
DOL-LW38 Revised 11/15
LIVING WAGE CERTIFICATION/DECLARATION – SUBJECT TO AUDIT
If either of the following definitions of ‘compensation’ (Living Wage Law Chapter 575 – 2) applies to the contractor’s/recipient’s
business or transaction with Suffolk County, the contractor/recipient must complete Sections 1, 3, 4 below; and Form LW-1 (Notice
of Application for County Compensation). If the following definitions do not apply, the contractor/recipient must complete
Sections 2, 3 and 4 below. Completed forms must be submitted to the awarding agency.
“Any grant, loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more than $50,000 which is realized
by or provided to an employer of at least ten (10) employees by or through the authority or approval of the County of Suffolk,” or
“Any service contract or subcontract let to a contractor with ten (10) or more employees by the County of Suffolk for the furnishing of
services to or for the County of Suffolk (except contracts where services are incidental to the delivery of products, equipment or
commodities) which involve an expenditure equal to or greater than $10,000. For the purposes of this definition, the amount of expenditure
for more than one contract for the same service shall be aggregated. A contract for the purchase or lease of goods, products, equipment,
supplies or other property is not ‘compensation’ for the purposes of this definition.”
Section I
The Living Wage Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County
Local Law No. 12-2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide to all full, part-time or temporary
employed persons who perform work or render services on or for a project, matter, contract or subcontract where this company has
received compensation, from the County of Suffolk as defined in the Law (compensation) a wage rate of no less than $11.93 ($9.25
for child care providers) per hour worked with health benefits, as described in the Law, or otherwise $13.58 ($10.50 for child care
p
ro
viders) per hour or the rates as may be adjusted annually in accordance with the Law. (Chapter 575-3 B)
I/we further agree that any tenant or leaseholder of this company that employs at least ten (10) persons and occupies property or uses
equipment or property that is improved or developed as a result of compensation or any contractor or subcontractor of this company
that employs at least ten (10) persons in producing or providing goods or services to this company that are used in the project or
matter for which this company has received compensation shall comply with all the provisions of the Law, including those
specified above. (Chapter 575-2)
I/we further agree to permit access to work sites and relevant payroll records by authorized County representatives for the purpose of
monitoring compliance with regulations under this Chapter of the Suffolk County Code, investigating employee complaints of
noncompliance and evaluating the operation and effects of this Chapter, including the production for inspection & copying of payroll
records for any or all employees for the term of the contract or for five (5) years, whichever period of compliance is longer. All
payroll and benefit records required by the County will be maintained for inspection for a similar period of time. (Chapter 575-7 D)
The Suffolk County Department of Labor, Licensing & Consumer Affairs shall review the records of any Covered Employer at least
once every three years to verify compliance with the provisions of the Law. (Chapter 575-4 C)
Section II The Living Wage Law does not apply to this contract for the following reason(s):_____________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Section III Contractor Name: _______________________________________ Federal Employer ID#: _________________
Contractor Address: _____________________________________________ Amount of compensation:__________________
______________________________________________________________ Vendor #:_______________________
Contractor Phone # ______________________ Description of project or service:______________________________________
_______________________________________________________________________________________________________
Section IV
I declare under penalty of perjury under the Laws of the State of New York that the undersigned is authorized to provide this
certification, and that the above is true and correct.
____________________________________________________________ _________________________
Authorized Signature Date
____________________________________________________________
Print Name and Title of Authorized Representative
Check if
applicable
