1-Payroll Certificationn.pdf
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- Clearfield County, Claysville Borough, Pennsylvania
About this file
This is a Weekly Payroll Certification form for Public Works Projects issued by the Pennsylvania Bureau of Labor Law Compliance, Prevailing Wage Division, applicable to contractors and subcontractors working on publicly funded construction projects in Pennsylvania. The form documents weekly payroll information for employees working on prevailing wage jobs, including employee names, work classifications, hours worked, hourly rates, fringe benefits, deductions, and gross pay. Contractors and subcontractors are required to complete all information weekly, with notarization required only on first and final submissions. The form serves as certification of compliance with Pennsylvania's prevailing wage requirements under the Prevailing Wage Act of August 15, 1961, P.L. 987, as amended.
The form requires contractors and subcontractors to certify that prevailing wage requirements and predetermined rates are included in their contracts, that they are not debarred by the Secretary of Labor and Industry, and that they have not subcontracted work to debarred entities. Contractors must specify all fringe benefits provided, including medical or hospital care, pension or retirement, life insurance, disability coverage, vacation and holiday pay, and other benefits, with contributions calculated per hour. The certification includes a statement that willful falsification of any information may subject the contractor to civil or criminal prosecution under Pennsylvania law. This form is directly relevant to the Myers Farm Agricultural Best Management Practice Installation project in Clearfield County, which is funded by the Pennsylvania Department of Environmental Protection and State Conservation Commission and is subject to prevailing wage requirements.
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Text version
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)
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