MTO Request to Sublet Form - Minnesota Department of

Minnesota Department of Transportation
Multiple Trucking Company (MTO) Request to Sublet Form
(Updated 9/14/2016)
Prime Contractor Information
Prime Contractor Name:
Telephone Number:
State Contract / Project Number:
Fax Number:
Project Location:
Email:
Important Notices and Instructions
1. The Prime Contractor must complete this form, acquire applicable signatures, and submit it to the Project Engineer (P.E.)
prior to the first day of work by the Multiple Trucking Firm (MTO).
2. Upon approval, the P.E. will sign the form and provide a copy to the Prime Contractor.
3. A MTO that is subject to the contract must submit certified payroll reports to the Prime Contractor.
4. Each MTO must submit an IC-134 form to the Prime Contractor upon completion of the work.
5. Each MTO must be included on a MTO Month-End Trucking Report.
Multiple Trucking Company Information
MTO Company Name:
Vendor (SWIFT) ID:
Street Address:
Federal Tax I.D. Number:
City, State, Zip Code:
Minnesota Tax I.D. Number:
Telephone Number:
Email:
Fax Number:
Name of contractor/vendor that hired the MTO:
Contract Item
No.
Contract Item Description
Vendor (SWIFT) ID Number:
Estimated
Quantity
Unit of
Measurement
Unit
Price
Amount
$
$
Total
CONTRACTOR’S STATEMENT OF COMPLIANCE
Print Name and Title of Prime Contractor Representative
Signature
$
Date
As a representative of the Prime Contractor, I hereby certify that the information described on this form is truthful and accurate to the best
of my knowledge and that: All subcontracts are in writing and contain the appropriate requirements and provisions from the prime contract
for the work performed by the individual subcontractor which includes: Special Provisions Division A, Federal and/or State wage
determinations and the State certified truck rental rates. All subcontractors have viewed the Prevailing Wage Pre-construction videos and
meeting agenda located on the MnDOT, LCU website prior to signing this document. All subcontractors are meeting the requirements of
Minn. Stat. 16C.075 E-Verify and I have verified that all subcontractors are not suspended or debarred by any governmental agency. By
signing this document, I certify that each subcontractor listed on this document has verified in writing to me that it is a “Responsible
Contractor” as defined in Minnesota Statutes §16C.285, subdivision 3.
Print Name and Title of MTO Subcontractor Representative
Signature
Date
As a representative of the Multiple Trucking Company, I hereby certify that: All company information listed in the Information area above
is true and accurate, I’ve reviewed our written subcontract and understand all applicable contract requirements and specifications for the
work we will be performing on the contract, which includes but are not limited to: Special Provisions Division A, Federal and/or State wage
determinations, State certified truck rental rates. By signing this document, I certify that our company is a “Responsible Contractor”
as defined in Minnesota Statutes §16C.285, subdivision 3.
Print Name and Title of Project Engineer
Signature
Date
As a representative of the Department, I approve the Prime Contractor’s utilization of the above-mentioned Subcontractors. Additionally, the Prime
Contractor has complied with the terms established in MnDOT Standard Specifications for Construction, Section 1801.
All persons signing this form understand that willful falsification of this document may result in civil and/or criminal prosecution under federal and/or state law. See Minnesota
Statutes 16B, 161.315 Subdivision 2, 177.43 Subdivision 5, 177.44 Subdivision 6, 609.63; or the United States Code 18 U.S.C. 1001, 31 U.S.C. 231, CFR 5.12.