REQUEST FOR AUTHORIZATION OF
ADDITIONAL CLASSIFICATION AND RATE
INSTRUCTIONS: THE CONTRACTOR SHALL COMPLETE ITEMS 3 THROUGH 16, KEEP A PENDING COPY, AND SUBMIT THE REQUEST, IN
QUADRUPLICATE, TO THE CONTRACTING OFFICER.
1. TO:
ADMINISTRATOR,
WAGE AND HOUR DIVISION
U.S. DEPARTMENT OF LABOR
WASHINGTON, DC 20210
2. FROM: (REPORTING OFFICE)
3. CONTRACTOR 4. DATE OF REQUEST
5. CONTRACT NUMBER
6. DATE BID OPENED (SEALED
BIDDING)
7. DATE OF AWARD
8. DATE CONTRACT WORK
STARTED
9. DATE OPTION EXERCISED (If
APPLICABLE) (SERVICE
CONTRACT ONLY)
10. SUBCONTRACTOR (IF ANY)
11. PROJECT AND DESCRIPTION OF WORK (ATTACH ADDITIONAL SHEET IF NEEDED)
12. LOCATION (CITY, COUNTY, AND STATE)
13. IN ORDER TO COMPLETE THE WORK PROVIDED FOR UNDER THE ABOVE CONTRACT, IT IS NECESSARY TO ESTABLISH THE FOLLOWING RATE(S) FOR THE
INDICATED CLASSIFICATION(S) NOT INCLUDED IN THE DEPARTMENT OF LABOR DETERMINATION
NUMBER:
DATED:
a. LIST IN ORDER: PROPOSED CLASSIFICATION TITLE(S); JOB DESCRIPTION(S); DUTIES;
AND RATIONALE FOR PROPOSED CLASSIFICATIONS (Service contracts only)
b. WAGE RATE(S)
c. FRINGE BENEFITS
PAYMENTS
(Use reverse or attach additional sheets, if necessary)
14. SIGNATURE AND TITLE OF SUBCONTRACTOR REPRESENTATIVE
(IF ANY)
15. SIGNATURE AND TITLE OF PRIME CONTRACTOR REPRESENTATIVE
16. SIGNATURE OF EMPLOYEE OR REPRESENTATIVE TITLE
CHECK APPROPRIATE BOX-REFERENCING BLOCK 13.
AGREE DISAGREE
TO BE COMPLETED BY CONTRACTING OFFICER (CHECK AS APPROPRIATE - SEE FAR 22.1019 (SERVICE CONTRACT LABOR
STANDARDS) OR FAR 22.406-3 (CONSTRUCTION WAGE RATE REQUIREMENTS))
THE INTERESTED PARTIES AGREE AND THE CONTRACTING OFFICER RECOMMENDS APPROVAL BY THE WAGE AND HOUR DIVISION. AVAILABLE
INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
THE INTERESTED PARTIES CANNOT AGREE ON THE PROPOSED CLASSIFICATION AND WAGE RATE. A DETERMINATION OF THE QUESTION BY THE WAGE
AND HOUR DIVISION IS THEREFORE REQUESTED. AVAILABLE INFORMATION AND RECOMMENDATIONS ARE ATTACHED.
(Send 3 copies to the Department of Labor)
SIGNATURE OF CONTRACTING OFFICER OR REPRESENTATIVE
STANDARD FORM 1444 (REV. 4/2013)
Prescribed by GSA-FAR (48 CFR) 53.222(f)
TITLE AND COMMERCIAL TELEPHONE NUMBER DATE SUBMITTED
CHECK APPROPRIATE BOX
SERVICE CONTRACT
CONSTRUCTION CONTRACT
PREVIOUS EDITION IS USABLE
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Expiration Date: 4/30/2022
AUTHORIZED FOR LOCAL REPRODUCTION
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Phoenix, AZ 85007
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