KSU Tri-Towers Rotunda All Subcontractor and Lower Tier

KSU Tri-Towers Rotunda
All Subcontractor and Lower Tier Subcontractors’
Compliance Reporting Requirements
1.
Payroll Authorization (Complete only if the owner is not signing payroll - signed in Blue Ink)
 One form must be completed for each person who is authorized to sign payroll
reports for your company.
 This form is due one time at the beginning of the project and for ALL
additional persons authorized to sign payrolls.
2.
Owner/Operator Affidavit

3.
Required by all owner operators at the beginning of the project
Certified Payroll (signatures must be signed in Blue Ink)
 Due on a weekly basis
 All payrolls will be submitted via email to [email protected] AND
[email protected] and two originals mailed to:
Diana Correa/Brianna Niznik
1702 Joseph Lloyd Parkway
Willoughby, OH 44094

Certified Payrolls MUST include the following information
• Full Social Security Numbers
• Race and Gender
• Work Classification and Craft
• Base Hourly Rates
• Fringes
• Original Signature (signed in Blue ink)

If you are not on site for the week and plan to return, you will need to submit
“No Work Performed” payrolls.
4.
Statement of Compliance
 Complete and staple to the back of each payroll prior mailing them in.
5.
Final Affidavit of Compliance
 Your Final Affidavit of Compliance shall be completed, signed, notarized and
submitted via email and mail the original.
 Dates must correspond to your certified payrolls that were submitted.
*Please note that if all documentation detailed above is not submitted in a timely manner, by
the subcontractor or any lower tiers, Marous Brothers Construction may be forced to pull your
company from the monthly billing, holding up your payment(s). Until you have submitted all
required documents AND all documents have been processed and approved, your payment(s)
will be held.
KSU Tri-Towers Rotunda
All Subcontractor and Lower Tier Subcontractors’
Compliance Reporting Requirements
If you have any questions or need additional assistance, please do not hesitate to contact us.
Diana Correa
Compliance Manager
440-391-5427
[email protected]
Brianna Niznik
Compliance Administrator
440-391- 5353
[email protected]
Candice Cunningham
Subcontract Administrator
440-391-5488
[email protected]
City of Cleveland
Office of Equal Opportunity
Prevailing Wage Compliance
601 Lakeside Avenue, Room 335
Cleveland, Ohio 44114
PAYROLL SIGNATURE
AUTHORIZATION
Phone: 216.664.4151 
Fax: 216.664.3870 
Email: [email protected] 
Hours: 8 am to 5 pm Weekdays
PROJECT INFORMATION
PROJECT NAME:
DATE:
FEDERAL WAGE DECISION &
MODIFICATION #:
CITY CONTRACT #:
CONTRACTOR:
PHONE:
MAIN CONTACT:
EMAIL:
CONTRACTOR INFORMATION
PAYROLL CLERK(S) & OTHER DESIGNEE(S)
The following individuals will serve as the authorized signatory party for weekly certified payroll reports
and may speak on behalf of our company regarding the weekly data entry of payroll reports on the
aforementioned contract on our behalf:
1.
2.
3.
EMPLOYEE NAME:
TITLE:
EMPLOYEE SIGNATURE:
DATE:
EMPLOYEE NAME:
TITLE:
EMPLOYEE SIGNATURE:
DATE:
EMPLOYEE NAME:
TITLE:
EMPLOYEE SIGNATURE:
DATE:
CONTRACTOR OFFICIAL ACKNOWLEDGEMENT & AUTHORIZATION
COMPANY OFFICIAL
TITLE
SIGNATURE
DATE
IMPORTANT: You are required to notify (1) the City of Cleveland and (2) the Prime Contractor in writing via e-mail, fax, LCPtracker, or
mail with any changes, additions, or deletions in personnel roles prior to submission of a payroll “statement of compliance” with their
authorization and/or signature.
STATEMENT REQUIRED BY REGULATIONS, PARTS 3 AND 5: While the "statement of compliance" that accompanies payroll reports
need not be notarized, the statement is subject to the penalties provided by 18 U.S.C. § 1001, namely, a fine, possible imprisonment of not
more than 5 years, or both. Accordingly, the party signing this statement should have knowledge of the facts represented as true.
DIRECTIONS FOR COMPLETED FORM:
1. Upload Completed Form to LCP tracker (https://lcpprod.lcptracker.net/).
2. Email Completed Form to Prime Contractor and/or the project’s Prevailing Wage Coordinator.
CF 12 - PAYROLL SIGNATURE AUTHORIZATION (Rev. 11/29/12)
CF 12
City of Cleveland
Office of Equal Opportunity
Prevailing Wage Compliance
601 Lakeside Avenue, Room 335
Cleveland, Ohio 44114
OWNER / OPERATOR AFFIDAVIT Phone: 216.664.4151  Fax: 216.664.3870  Email: [email protected]  Hours: 8 am to 5 pm Weekdays
PROJECT INFORMATION
PROJECT NAME:
CITY CONTRACT #:
CONTRACTOR INFORMATION
COMPANY NAME:
PHONE:
PAYROLL CONTACT:
EMAIL:
STATEMENT OF WORK PERFORMED
I, ____________________________________________, hereby certify that I am the
(Insert Name of Signatory Party)
____________________________________of __________________________________
(Insert Owner, Partner, President, etc.)
(Insert Name of Company submitting statement)
and perform the following work ____________________________________________ and
(Insert type of work or list the specific classes of work)
certify that the work is being and/or was done by me personally.
REQUIRED PROOF & DOCUMENTATION
Enclose a copy of any of the following documentation proving the individual’s ownership of the business. More than one form may be required. If
the supplied documentation does not prove ownership, you will not be considered an Owner/Operator and will have to pay and report prevailing
wages for yourself.
 Trade Name Registration
 Vehicle Registration (Trucking Companies Only)
 Articles of Incorporation
 Certificate of Auto Insurance (Trucking Companies Only)
 Form 1040 Schedule C (most recent)
Hours worked on this job must be submitted on the weekly certified payroll form; W-9 form is not acceptable. Federal ID # is not acceptable.
Falsification of any of the above may subject the contractor to civil or criminal prosecution.
OWNER / OPERATOR / CONTRACTOR ACKNOWLEDGEMENT & AUTHORIZATION
_______________________________________________________
_________________________________________________
OWNER / OPERATOR / CONTRACTOR
TITLE
___________________________________________
SIGNATURE
___________________
DATE
NOTICE: YOUR SIGNATURE ABOVE CONSTITUTES AN OATH, AND A MATERIALLY FALSE STATEMENT TO INDUCE PAYMENT BY THE CITY MAY
SUBJECT YOU TO CRIMINAL PROSECUTION FOR PERJURY.
DIRECTIONS FOR COMPLETED FORM:
1. Upload Completed Form to LCP tracker (https://lcpprod.lcptracker.net/).
2. Email Completed Form to Prime Contractor and/or the project’s Prevailing Wage Coordinator.
CF 40 - OWNER OPERATOR AFFIDAVIT (Rev. 11/30/12)
CF 40