HomeMy WebLinkAbout2026_LSLR_Payment_Request_Form
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Payment Request Form_2-20-26.docx
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UPDATED
2026 CONTRACTOR PAYMENT APPLICATION FOR
PRIVATE-SIDE LEAD WATER SERVICE LINE REPLACEMENT
Approval of financial assistance for the lead service line replacement at any property is
required prior to commencing work. If the property was not approved for financial
assistance or the Contractor was not prequalified, the City of Oshkosh (City) will not process
the payment application. Any conditions of the approval must have been followed to be
eligible for financial assistance.
Lead Service line replacement should be coordinated so the public-side and private-side are
completed within 90 days of each other, and must be done within 180 days of either side
becoming lead-free. Failure to meet the 180-day requirement may result in the property not
being eligible for financial assistance, and the City will not pay the contractor.
This Payment Application form will not be processed unless completely filled out, signed,
dated, and returned with a copy of the itemized invoice, itemized BABA tracking spreadsheet,
and wage compliance documentation. In the event the hard surface restoration is not
completed due to a City-imposed halt of Right-of-Way (ROW) pavement installation,
payment for the service line replacement and related electrical work will be paid to the
contractor, providing all relevant documentation is submitted, and an approved final
inspection(s) has taken place. Any invoice submitted must clearly show that hard surface
work is to be completed later. By signing this document, Contractor asserts that they will
complete the remaining hard surface work within 45 days of the ROW pavement installation
being allowed by the City. A second Payment Application for the remaining work must be
submitted for payment along with all of the supporting documentation.
Property Address:
Property Owner(s):
Plumber/Utility Contractor Contact Name:
Plumbing/Utility Contractor Company Name:
Return to Tracy Taylor:
Via e-mail: dpw@oshkoshwi.gov
Via mail: Department of Public Works
PO Box 1130
Oshkosh, WI 54903-1130
In person: Room 301, City Hall
215 Church Avenue
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Is all work complete? (check one): All Work Complete Hard Surface Work Not
Complete
Is this a second Payment Application for the payment of ROW restoration?
(check one): Yes No
Date Work Completed: _ Invoice Amount:
A meeting must be set up with Maria Fletcher (920-236-5058) to complete, sign, and have
notarized the Promissory Note, Covenant, and Mortgage; or for the property owner to complete,
sign, and have notarized the Promissory Note and Covenant and to provide payment of the
remaining fifty percent (50%) of the cost of private-side lead water service lateral replacement.
This must be completed prior to the City paying the final invoice. This does not apply to
properties within 100% Financial Assistance Census Tract areas.
We, the undersigned, hereby certify that the information provided on and with this application is true
and accurate to the best of our knowledge. We further certify to the Use of American Iron and Steel, as
mandated in the U.S. Environmental Protection Agency's State Revolving Fund programs; to following
all applicable State regulations, including Ch. 145, Wis. Stats., SPS 382 and 384, Wis. Admin. Code,
and applicable local ordinances and regulations; and that all private-side lead water service lateral
replacements resulted in the complete removal of the private-side lead water service lateral and associated
materials from the property’s curb stop to the water meter within the structure. We also certify that a
good-faith effort was made to solicit subcontractors (if used) meeting the DBE requirements. The Use of
American Iron and Steel certification in the paragraph above means that, if the current private-
side lead lateral is replaced with a galvanized iron lateral, additional information will be
required from the plumbing/utility contracting firm to document the source of the galvanized
iron to maintain the property owner’s eligibility for reimbursement. The City highly
recommends that the lead laterals not be replaced with galvanized iron laterals.
By signing this payment application, Contractor certifies they have reviewed documentation
for all products and materials submitted for payment, and the documentation is sufficient to
demonstrate compliance with the Build America, Buy America Act requirements.
DAVIS-BACON WAGE RATE REQUIREMENTS
Funding for private-side lead water service line replacement is being provided by the U.S.
Environmental Protection Agency. Therefore, the Federal Davis-Bacon wage rate requirements
will apply in the following circumstances:
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• The property is owned by an individual or individuals or is in the name of a business.
• The work will be performed using an LSLR Contractor and/or subcontractor(s) that have
employees (who are not at least twenty percent (20%) owners of those firms); and an owner
of that LSLR Contractor and/or subcontractor(s) did not perform one hundred percent
(100%) of the work.
Davis-Bacon wage rate requirements will not apply in the following circumstances:
• An employee who is at least a twenty percent (20%) owner of the LSLR Contractor and/or
subcontractor(s) completing the work completes one hundred percent (100%) of the work.
• The total cost of the LSL replacement is less than two thousand dollars ($2,000).
The City will assist in determining whether or not the Davis-Bacon wage rate requirements
apply.
The LSLR Contractor and subcontractor(s) must obtain a copy of the Davis-Bacon wage rate
determination that is in effect when they sign the contract for the work that requires compliance
with the Davis-Bacon wage rates. The Davis-Bacon wage rates can be located at the following
website:
https://sam.gov/content/wage-determinations
Under “I do not know the number”, select “Public Building or Works” on the first screen and
the construction type to be selected on the second screen is “Heavy”. For all wage rates,
except for the Plumber wage rate, use the Wage Rate Determination that states “Construction
Types: Heavy (Sewer and Water Line and Tunnel)”. For the Plumber wage rate, use the
Wage Rate Determination that states “Construction Type: Heavy”. For both Wage Rate
Determinations, use the Winnebago County wage rates.
The LSLR Contractor and subcontractor(s) must also provide a certified payroll to the City with
the financial assistance application form. Please contact the City to get the required certified
payroll form.
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By signing below, the parties agree that all work related to the replacement of the private-
side lead service line has been completed and that all information on this form is correct.
Both parties affirm the City will pay the Plumber/Utility Contractor directly the full amount
of the work, up to $6,700; and the Property Owner will enter into a loan agreement with the
City to repay fifty percent (50%) of the work, up to $3,350 plus a sixty-dollar ($60) fee, or the
Property Owner will immediately pay the City the remaining fifty percent (50%) of the work.
For properties in the eligible Census Tracks, no loan agreement or payment will be required.
Plumber’s/Utility Contractor’s Signature Property Owner’s Signature
Date Date
Phone Phone
E-mail Address E-mail Address
THIS SECTION TO BE COMPLETED BY CITY
*************************************************************************************************************
Lateral replacement verified: By Whom:
Right-of-Way hard surface
replacement verified:___________________________ By Whom:
Approved Contractor payment amount:
Property Owner repayment amount:
Staff Signature: _ Date: ___________________________