00 73 43-1 - Certification Form llc-25 PA Dep L&I.pdf

LLC-25 REV 10-03 (Page 1)

WEEKLY PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS

Contractor or Subcontractor (Please check one) ALL INFORMATION MUST BE COMPLETED

BUREAU OF LABOR LAW COMPLIANCE

PREVAILING WAGE DIVISION

7TH & FORSTER STREETS

HARRISBURG, PA 17120

1-800-932-0665

CONTRACTOR SUBCONTRACTOR

ADDRESS ADDRESS

PAYROLL NUMBER WEEK ENDING DATE PROJECT AND LOCATION

PROJECT SERIAL # PROJECT #

EMPLOYEE NAME

APPR.

RATE

WORK

CLASSIFICATION

DAY AND DATE

HOURS WORKED EACH DAY

S-

TIME

0-

TIME

BASE

HOURLY

RATE

TOTAL FRINGE

BENEFITS

(C=Cash)

(FB=Contributions)*

TOTAL

DEDUCTIONS

GROSS PAY

FOR

PREVAILING

RATE JOB(S)

CHECK #

C:

FB:

C:

FB:

C:

FB:

C:

FB:

C:

FB:

*SEE REVERSE SIDE

PAGE NUMBER ___________ OF ____________

THE NOTARIZATION MUST BE COMPLETED ON FIRST AND LAST SUBMISSIONS ONLY. ALL OTHER

INFORMATION MUST BE COMPLETED WEEKLY.

*FRINGE BENEFITS EXPLANATION (FB): Bona fide benefits contribution, except those required by Federal or State Law (unemployment tax, workers’ compensation, income taxes, etc.)

Please specify the type of benefits provided and contributions per hour:

1) Medical or hospital care__________________________________________________________________________

2) Pension or retirement ____________________________________________________________________________

3) Life insurance _________________________________________________________________________________

4) Disability _____________________________________________________________________________________

5) Vacation, holiday _______________________________________________________________________________

6) Other (please specify) ___________________________________________________________________________

CERTIFIED STATEMENT OF COMPLIANCE

1. The undersigned, having executed a contract with _____________________________________________________

______________________________ for the construction of the above-identified project, acknowledges that:

(a) The prevailing wage requirements and the predetermined rates are included in the aforesaid contract.

(b) Correction of any infractions of the aforesaid conditions is the contractor’s or subcontractor’s responsibility.

(c) It is the contractor’s responsibility to include the Prevailing Wage requirements and the predetermined rates in any subcontract or lower tier subcontract for this project.

2. The undersigned certifies that:

(a) Neither he nor his firm, nor any firm, corporation or partnership in which he or his firm has an interest is debarred by the Secretary of Labor and Industry pursuant to Section 11(e) of the PA Prevailing Wage Act, Act of August 15, 1961, P.L. 987 as amended, 43 P.S.§ 165-11(e).

(b) No part of this contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation or partnership in which such subcontractor has an interest is debarred pursuant to the aforementioned statute.

3. The undersigned certifies that:

(a) the legal name and the business address of the contractor or subcontractor are: _________________________

(b) The undersigned is:

(c) The name, title and address of the owner, partners or officers of the contractor/subcontractor are:

The willful falsification of any of the above statements may subject the contractor to civil or criminal prosecution, provided in the PA Prevailing Wage Act of August 15, 1961, P.L. 987, as amended, August 9, 1963, 43 P.S. § 165.1 through 165.17.

(AWARDING AGENCY, CONTRACTOR OR SUBCONTRACTOR)

a single proprietorship a corporation organized in the state of ______________ a partnership other organization (describe) ____________________________

NAME TITLE ADDRESS

(DATE)

SEAL

(SIGNATURE)

(TITLE)

Taken, sworn and subscribed before me this _________ Day of ___________________________________ A.D., ___________LLC-25 REV 10-03 (Page 2)