Guidance for Preparing An

Drinking Water Revolving Loan Fund

DAVIS-BACON AND RELATED ACTS PAYROLL CERTIFICATION

Louisiana Department Of Health And Hospitals  Office Of Public Health

Davis-Bacon and Related Acts Payroll Certification

NOTE: This certification is required for all projects receiving funding from DWRLF that must comply with Davis-Bacon requirements as indicated in the loan closing documents. All Payment Requests seeking reimbursement for construction costs must include this certification.

Name of Water System: ______

Name of Project: ______DWRLF Project No. ______

Contractor / Subcontractor: ______

Weekly Payroll Numbers and Dates Covered by this Certification:

Payroll No.: ______From:______To: ______Comments: ______

Interview Verifications:

Recipients must conduct a minimum of two interviews: the first within two weeks of initial payroll submission, and the second two weeks prior to the completion date of the contract or sub-contract. Additional interviews should be performed if problems are found during the initial interview and at other times when needed. An interview form (Standard Form 1445 or equivalent) must be completed with every interview and kept on file.

Initial Interview Date: ______Interview Date: ______Interview Date: ______

Interview Date: ______Interview Date: ______Final Interview Date: ______

CERTIFICATION

I certify to the best of my knowledge and belief that the above referenced project complies with the Davis-Bacon and Related Acts requirements as indicated in the loan closing documents and that all laborers and mechanicsemployed by contractors and subcontractors during the above referenced period were paid wages at rates notlessthan those listed on the prevailing wage rate contained in the contract documents and that all applicable provisionsof the Davis-Baconand Related Acts have been met.

Name of Certifying Official: / Title of Person Certifying:
Signature: / Phone Number: / Date Signed:

Payrolls and basic records must be maintained by the contractor for three years from project completion.

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