Request for Determination - Public Body

The Great Seal of the State of New Jersey

The form that follows this section may be used by public bodies that are requesting an Official Wage Rate Determination pursuant to The New Jersey Prevailing Wage Act (N.J.S.A. 34:11-56.25 et. seq. and N.J.S.A. 34:1B-5.1). All sections of the form pertaining to your type of request must be fully completed for approval. Upon execution of the completed form and delivery to the public body, this Determination will be considered the Official Wage Rate Determination for the public works project specified.

Name and Address of Public Body (Owner) Who Will be Awarding Contract
(First, Middle, Last)
Name of individual completing the form
Federal Employee Identification Number
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Mailing address of the individual
Project number used for form

(** indicates a required field)

Page 1 of 4