New York Form 112 – Fill Out and Use This PDF

City of New York	Form 112
Parks & Recreation

N.Y.C Department of Parks & Recreation

Labor Law Compliance

EMPLOYEE PREVAILING WAGE REQUIREMENT

1). I, _________________________, social security number _____________ residing at

_______________________________________have received and read the Prevailing Wage Schedule

NYS Labor Law, Section 220 presented to me by my employer ____________________.

2). I am currently performing work on a NYC Department of Parks & Recreation construction project known as ___________________________________________________, Contract No:_____________,

Registration No: ___________________ in the borough of _______________.

3). I am aware that my trade classification, __________________________, entitles me to the prevailing

Wage of $____ per hour and the supplemental benefit of $____ per hour.

4). I am also aware that if for any reason my employer fails to pay me the applicable wage rate and/or Supplemental benefit rate for my trade, it is my right to file a complaint with the NYC Department of Parks & Recreation; and file a complaint with the New York City-Office of the Comptroller against my employer.

__________________________________	_____________________________
(Employee’s Signature & Date)	Print Company’s name
__________________________________	By:__________________________
(Print Employee’s Name)	(Employer Signature & Date)
	Title:__________________________
	___________________________________
	(Employer Printed Name)
Sworn to me on this ____day of	Sworn to me on this ____day of
______________, 2010	______________, 2010
________________________	_______________________
Notary Public	Notary Public
Submit Form To: Borough Director, Resident Engineer	Revised 03/2010