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Contractor/Subcontractor Certification Anoka County Community Development Program This form must be executed and submitted before you begin work on this project. Payments will not be issued until all contract compliance forms are fully completed and submitted to the agency. The form is to be completed by each General Contractor, Subcontractor, Lower-Tier Subcontractor and should be returned to the General Contractor of this project. The prime contractor is responsible for submission of the form to the Agency’s Compliance Representative. Any changes in the information below must be submitted to the agency’s compliance representative. Project Name: Address: General Contractor: Address: Telephone Number: Federal Tax Identification Number: Is your business a Woman Owned Business Yes No : Which Racial/Ethnic Code is your business: White Black Native American Hispanic Asian/Pacific Hasidic Jews Are you a Section 3 Business? Yes No (Section 3 Business is defined as: one that is 51% or more owned by Section 3 residents; or one where at least 30% of its full-time, permanent employees are within three years of hire were Section 3 residents; or one that provides evidence of commitment to subcontract in excess of 25% of the dollar/contract award to businesses that meet one of the two previous definitions. A Section 3 resident is defined as: a public housing resident; or an individual who resides in the county in which Section 3 project is located is a low- or moderate-income person.) Construction start date: Construction end date: Please give a description of the work your company will perform on the project site: Person authorized to sign Certified Payroll Reports: ---PAGE BREAK--- Contractor/Subcontractor Certification (continued) Identify below the work classification(s) and applicable base wage rate payment for your employees who will perform work on the project site. Work Classification Base Rate of Pay The fringe benefit payment will be (check one): Paid directly to each employee in the amount of $ Paid to a nonunion benefit plan (or plans) in the amounts indicated below: Pension Medical Dental Other (Identify) Benefit funds are deposited into accounts maintained by Address: Phone Paid to a union benefit plan (or plans) in the amounts indicated below: Holiday Vacation Health& Welfare Dental Pension Other(Identify) Benefit funds are deposited into accounts maintained by Address: Phone # If additional space is needed to respond to any questions, please attach separate sheet. Information included within this certification may be shared with the U.S. Department of Housing and Urban Development, Minnesota Department of Labor and Industry and the Anoka County Community Development Department. Owner/Principal Signature Date