2060023200DOLPayrollForm.pdf

WEEKLY PAYROLLDepartment of Labor Bureau of Public Work For Contractor's Optional Use. The use of this form meets payroll notification requirements; as stated on the Payroll Records Notification.

NAME OF CONTRACTOR SUBCONTRACTOR ADDRESS

FEIN FOR WEEK ENDING PROJECT OR CONTRACTOR NO.PROJECT AND LOCATION

(a)4) DAY AND DATE (9)(1) (2) (3) (6)(5) (7)

NET WAGESDEDUCTIONSSTNAME, ADDRESS, AND NO. OF GROSSRATE

PAIDWITH-LAST 4 DIGITS OF SOCIAL SECURITY NUMBER WORK or AMOUNTOFTOTAL

WITH-

HOLDING

Tax

FOR WEEKTOTALHOLDINGS CLASSIFICATION OT EARNEDPAYHOURS

HOURS WORKED EACH DAY

s s s s s s s s s

PW -12 (12-09)

OF EMPLOYEE

FICA OTHER DEDUCTIONS

THIS CERTIFICATION MUST BE COMPLETED ON EACH WEEKLY PAYROLL FORM USED BY THE CONTRACTOR OR SUBCONTRACTOR

Date

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

I (Name of signatory party) (Title) - Each laborer, worker, or mechanic listed in the above-referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below.

do hereby state:

(1) That I pay or supervise the payment of the persons employed by

(c) EXCEPTIONS

(Contractor or Subcontractor)

, that during the payroll period commencing on the day of 20day of, 20 , and ending the all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said EXPLANATIONEXCEPTION (CRAFT) from the full (Contractor or Subcontractor) weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Articles 8 and 9 and described below:

(2) That any payrolls submitted for the above period are correct and complete; that the wage rates for laborers, workers, or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer, worker or mechanic conform with the work he/she performed.

REMARKS:

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

- In addition to the basic hourly wage rates paid to each laborer, worker or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c).

SIGNATURE

THE WILLFUL FALSIFICATION OF ANY Of THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR

TO CIVIL OR CRIMINAL PROSECUTION. SEE ARTICLES 8 AND 9.