Wage Theft Prevention Application Verification Form
Last Updated: April 2025
This Wage Theft Verification Form is required by Minnesota Statute 462A.051 for all multiunit residential housing projects applying for funding from Minnesota Housing, including any loan and federal low-income housing tax credits. If the ownership entity exists at the time of application submittal, the Owner must complete and sign this Verification Form and submit it with their application. If the ownership entity does not exist at the time of application, the Project Sponsor must complete and sign this Verification Form and submit it with their application. If contractors and/or subcontractors are added to a project after the date of this verification, an additional verification form will be required with information for all contractors at a time designated by Minnesota Housing. 
Notice to Owner/Project Sponsor
As a condition of receiving funding from Minnesota Housing, the project applicant shall maintain a list of every contractor and subcontractor of any tier that performs work or is expected to perform work on the proposed project consistent with Minn. Stat. 16C.285, subdivision 5, including (for each contractor and/or subcontractor):
•	Business name
•	Scope of work
•	Department of Labor and Industry registration number
•	Business name of the entity contracting its services
•	Business telephone number
•	Business email address
•	Actual or anticipated number of workers on the project
As a condition of receiving funding from Minnesota Housing, project sponsors must verify that every contractor or subcontractor of any tier performing work on the proposed project meets the minimum criteria to be a responsible contractor set out by Minn. Stat. 16C.285, subd. 3. Those criteria are as follows:
(1)	The contractor:
(i)	Is in compliance with workers’ compensation and unemployment insurance requirements;
(ii)	Is in compliance with Department of Revenue and Department of Employment and Economic Development registration requirements if it has employees;
(iii)	Has a valid federal tax identification number or a valid Social Security number if an individual; and
(iv)	Has filed a certificate of authority to transact business in Minnesota with the secretary of state if a foreign corporation or cooperative;
(2)	The contractor or related entity is in compliance with and, during the three-year period before submitting the verification, has not violated section 177.24, 177.25, 177.41 to 177.44, 181.03, 181.101, 181.13, 181.14, or 181.722, and has not violated United States Code, title 29, sections 201 to 219, or United States Code, title 40, sections 3141 to 3148 (Davis Bacon Act). For purposes of this clause, a violation occurs when a contractor or related entity:
(i)	repeatedly fails to pay statutorily required wages or penalties on one or more separate projects for a total underpayment of $25,000 or more within the three-year period, provided that a failure to pay is "repeated" only if it involves two or more separate and distinct occurrences of underpayment during the three-year period;
(ii)	has been issued an order to comply by the commissioner of labor and industry that has become final;
(iii)	has been issued at least two determination letters within the three-year period by the Department of Transportation finding an underpayment by the contractor or related entity to its own employees;
(iv)	has been found by the commissioner of labor and industry to have repeatedly or willfully violated any of the sections referenced in this clause pursuant to section 177.27;
(v)	has been issued a ruling or findings of underpayment by the administrator of the Wage and Hour Division of the United States Department of Labor that have become final or have been upheld by an administrative law judge or the Administrative Review Board;
(vi)	has been found liable for underpayment of wages or penalties or misrepresenting a construction worker as an independent contractor in an action brought in a court having jurisdiction; or
(vii)	has been convicted of a violation of section 609.52, subdivision 2, clause (19).
(3)	The contractor or related entity is in compliance with and, during the three-year period before submitting the verification, has not violated section 181.723 or chapter 326B. For purposes of this clause, a violation occurs when a contractor or related entity has been issued a final administrative or licensing order;
(4)	The contractor or related entity has not, more than twice during the three-year period before submitting the verification, had a certificate of compliance under section 363A.36 revoked or suspended based on the provisions of section 363A.36, with the revocation or suspension becoming final because it was upheld by the Office of Administrative Hearings or was not appealed to the office;
(5)	The contractor or related entity has not received a final determination assessing a monetary sanction from the Department of Administration or Transportation for failure to meet targeted group business, disadvantaged business enterprise, or veteran-owned business goals, due to a lack of good faith effort, more than once during the three-year period before submitting the verification;
(6)	The contractor or related entity is not currently suspended or debarred by the federal government or the state of Minnesota or any of its departments, commissions, agencies, or political subdivisions that have authority to debar a contractor; and
(7)	All subcontractors and motor carriers that the contractor intends to use to perform project work have verified to the contractor through a signed statement under oath by an owner or officer that they meet the minimum criteria listed in clauses (1) to (6).

Verification
 [NAME] , the  [TITLE]  of  [ENTITY NAME] , hereby attests that:
A.	Each contractor or subcontractor who will perform any work for the proposed  [NAME OF PROJECT]  project pursuant to the applicable funding satisfies the minimum criteria described in the Notice to Owner, above.
B.	I (We) agree to provide verifications of compliance from each additional subcontractor who is retained subsequent to this date of verification at a time designated by Minnesota Housing.
C.	I (We) will establish the initial contractor list at least 30 days before the start of construction and will update the list each month thereafter until construction is complete.
D.	I (We) will place the contractor list in a conspicuous location at the project site and make the contractor list available to members of the public upon request.
E.	I (WE) understand and agree that:
1.	Minnesota Housing must deny an application for funding that does not include this verification.
2.	Once the application has been selected Minnesota Housing may withhold funding that has been previously approved if it determines that the project sponsor has engaged in unacceptable practices by failing to abide by the agreements set forth in this verification. Any withheld funding will resume once the noncompliance is cured.
I declare under penalty of perjury that everything I have stated in this document is true and correct.
Signature
This Wage Theft Prevention Verification Form is being signed by the  of the project.
     	     
Authorized Signatory Printed Name	Title
     	     
Authorized Signature	Date