21_PW_CERTIFIED_PAYROLL_REPORT_-_OHIO_(2024.12.27).pdf
PDF 55 KB Posted
- Attached to
- Payne Avenue Improvements
- Solicitation number
- AR2612
- Issued by
- Cuyahoga County, Ohio
About this file
This is a Certified Payroll Report form (F330-03A and F330-03B) issued by the State of Ohio for public facility construction projects. The form is used by contractors and subcontractors working on public construction projects in Ohio to document and certify prevailing wage compliance. The report requires contractors to provide detailed information about all workers employed on a project, including worker names, identifying numbers, work classifications, hours worked by date, prevailing wage rates, fringe benefits paid, and deductions. The form must be completed for each pay period and submitted to the contracting authority overseeing the project.
The contractor or subcontractor must certify under penalty of law that all hours have been paid at appropriate prevailing wage rates, all required fringe benefits have been paid in accordance with approved plans, no unauthorized rebates or deductions have been made from wages except as permitted under Ohio Revised Code Chapter 4115, and all apprentices are properly registered with the U.S. Department of Labor. Part B of the report requires submission of complete worker information including full names, Social Security numbers, and addresses on a separate sheet to comply with applicable prevailing wage laws. Willful falsification of the certification statements subjects contractors and subcontractors to civil or criminal prosecution. The form is a standard requirement for the City of Cleveland's capital projects managed through the Mayor's Office of Capital Projects.
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Text version
F330-03Av0612 1If Subcontractor, provide Contractor name in space provided. 2Attach additional pages as necessary. 3Text will wrap. 4Text will fit to cell.
My signature on this form signifies that I pay, or supervise the payment of the employees shown above. I am certifying: 1) That during the pay period reported on this form, all hours worked on this Project have been paid at the appropriate prevailing wage rate for the class of work done. 2) That the fringe benefits have been paid as indicated above. 3) That no rebates or deductions have been or will be made, directly or indirectly from the total wages earned, other than permissable deductions as defined in Ohio Revised Code Chapter 4115. 4) That apprentices are registered with the U.S. Department of Labor, Bureau of Apprenticeship and Training. I understand that the willful falsification of any of the above statements may subject the Contractor or Subcontractor to civil or criminal prosecution. In addition, I have submitted the full Name, Social Security Number, and Address of each Worker on a separate sheet (Part B) to form the entire Certified Payroll Report required by Applicable Law.
Signature: Date:Type or Print Name and Title:
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9. TTL
HRS
ALL
JOBS
7.
PROJ
GROSS
WAGES
W TH F
PAYROLL NUMBER
S of
Certified Payroll Report - Part A 330 Construction Contractor Payment State of Ohio Standard Forms for Public Facility Construction
11.
TAXES
WITH-
HELD
12.
OTHER
DEDUC-
TIONS
13.
NET
WAGES
PAID
APP OTHER
CASH8. FRINGES:
APPROVED PLANS
CASH AND APPROVED PLANS
PENS
M T
VAC
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4. HOURS WORKED - DAY AND DATE
1. NAME AND INDIVIDUAL
IDENTIFYING NUMBER (e.g., LAST
FOUR DIGITS OF SOCIAL SECURITY
NUMBER) OF WORKER
2. WORK
CLASS-
IFICA-
TION
3.
RACE
AND
SEX
H&W
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ST
10. TOTAL
GROSS
ALL JOBS
5.
TOTAL
PROJ
HRS
6.
BASE
WAGE
RATE
PAGE2
EMPLOYER NAME AND ADDRESS NAME OF GENERAL / PRIME CONTRACTOR PROJECT NAME AND LOCATION (COUNTY) CONTRACTING AUTHORITY (OR OWNER)
PROJECT / CONTRACT NUMBERWEEK ENDING CHECK IF SUBCONTRACTOR1
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F330-03Bv0612 1If Subcontractor, provide Contractor name in space provided. 2Attach additional pages as necessary. 3For Public Records Requests, redact Social Security Numbers.
FULL NAME OF WORKER SOCIAL SECURITY NUMBER3 STREET ADDRESS CITY, STATE AND ZIP CODE of
CHECK IF SUBCONTRACTOR1 WEEK ENDING PAYROLL NUMBER PAGE2 PROJECT / CONTRACT NUMBER
Certified Payroll Report - Part B 330 Construction Contractor Payment State of Ohio Standard Forms for Public Facility Construction EMPLOYER NAME AND ADDRESS NAME OF GENERAL / PRIME CONTRACTOR PROJECT NAME AND LOCATION (COUNTY) CONTRACTING AUTHORITY (OR OWNER)
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