Steven Bellone Frank Nardelli
Suffolk County Executive Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
DOL-LW1/38 (Revised 8/17)
NOTICE OF APPLICATION FOR COUNTY COMPENSATION
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. 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 $12.26 ($9.25 for child care providers) per hour worked with health benefits, as
described in the Law, or otherwise $13.95 ($10.50 for child care providers) 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)
IMPORTANT! IF SECTION I IS CHECKED, APPLICANT MUST PROVIDE THE FOLLOWING INFORMATION:
Projected Wage Levels:
Complete the chart below listing hourly wage rates, number of hours worked per week, compensated days off received yearly and indicate if medical
benefits are received for each employee dedicated to fulfilling the terms of this contract.
Note: Complete the following chart only if the Living Wage Law applies and if Section I above is checked.
Works less
than 20 hours
per week
(Yes or No)
Works 20
hours or more
per week
(Yes or No)
Employee
actually
receives health
benefits
(Yes or No)
Full-time employees receive at least 12
compensated days off per year. Part-time
employees receive prorated compensated
time off in increments proportional to full-
time employees (Yes or No)
Section II The Living Wage Law does not apply to this contract for the following reason(s): (Please check all that apply to this contract.)
Employ less than 10 employees Grant, loan, tax incentive or abatement, Amount of Compensation is less than $10,000.
Do not have any employees working in bond subsidy or other form of for the furnishing of services
Suffolk or Nassau Counties compensation is $50,000 or less. Other:
No cost to Suffolk County Pay prevailing wage rates
Section III Contractor Name: ____________________________________________ Federal Employer ID or SSN#: ___________________________
Contractor Address: ______________________________________________________ Amount of Compensation: _________________________________
_______________________________________________________________________ Term of Contract: ________________________________________
Contact Name: __________________________ Contractor Phone # ___________________ Awarding Agency: _______________________________
Contract ID #: ______________________________________ 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
click to sign
signature
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