A Statement of Compliance and Certified Payroll Form~46.pdf

07/23

WEEKLY STATEMENT OF COMPLIANCE

In accordance with Massachusetts General Law c. 149, §27B, a true and accurate record must be kept of all persons employed on the public works project for which the enclosed rates have been provided.

A Payroll Form is available from the Department of Labor Standards (DLS) at mass.gov/dols/pw and includes all the information required to be kept by law. Every contractor or subcontractor is required to keep these records and preserve them for a period of three years from the date of completion of the contract.

On a weekly basis, every contractor and subcontractor is required to submit a certified copy of their weekly payroll records to the awarding authority; this includes the payroll forms and the Statement of Compliance form. The certified payroll records must be submitted either by regular mail or by e-mail to the awarding authority. Once collected, the awarding authority is required to preserve those records for three years from the date of completion of the project.

Each such contractor and subcontractor shall furnish weekly and within 15 days after completion of its portion of the work, to the awarding authority directly by first-class mail or email, a statement, executed by the contractor, subcontractor or by any authorized officer thereof who supervised the payment of wages, this form, accompanied by their payroll:

WEEKLY STATEMENT OF COMPLIANCE

_______________, 20_______

I,___________________________________,___________________________________ (Name of signatory party) (Title) do hereby state:

That I pay or supervise the payment of the persons employed by

___________________________________ on the ______________________________ (Contractor, subcontractor or public body) (Building or project) and that all mechanics and apprentices, teamsters, chauffeurs and laborers employed on said project have been paid in accordance with wages determined under the provisions of sections twenty-six and twenty-seven of chapter one hundred and forty nine of the General Laws.

Signature _________________________

Title _____________________________

Project

Hours (A)

Project

Gross

Wages

Su. Mo. Tu. We. Th. Fr. Sa.

All Other

Hours

Total

Gross

Wages

APPRENTICESHIP DOCUMENTATION: Please answer the questions below.

(1) Are any apprentice employees identified above? YES NO

(2) If yes, are all apprentice employees identified above currently registered with the MA DLS Division of Apprentice Standards? YES NO

(3) If yes, is a copy of the apprentice ID card issued by the MA DLS Division of Apprentice Standards included for all apprentice employees identified above? YES NO

(B+C+D+E) (A x F)

General / Prime Contractor's Name: Subcontractor's Name:

Health &

Welfare

Insurance

(C/)

ERISA

Pension

Plan (D)

Supp.

Unemp.

(E/)

Total

Hourly

Prev.

Wage (F)

Check No.

(H)

Employee Name &

Complete Address

Work

Classification

Employee is OSHA 10 certified (?)

Appr.

Rate

Hours Worked Hourly

Base

Wage (B)

Project

Hours

Non-

Minority

Project

Hours

Minority

Project

Hours

Women

Public Works Project Name: Public Works Project Location: Min. Wage Rate Sheet Number:Awarding Authority Name:

Employer Hourly Fringe Benefit Contributions

Title: Contract No: Tax Payer ID #: Work Week Ending:Employer's Signature:

Address: Phone No.:

WEEKLY CERTIFIED PAYROLL REPORT AND WORKFORCE PARTICIPATION FORM

Payroll No.:

CERTIFIED PAYROLL REPORT: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.

WORKFORCE PARTICIPATION GOALS: The Commonwealth of Massachusetts has set the following goals for workforce participation for minorities and women. The participation goals for this project shall be

15.3% for minorities and 6.9% for women. The Contractor shall strive to achieve on this project the labor workforce participation goals contained herein. The Contractor shall enter the number of hours worked in each trade by each employee, identified as woman, minority, or non-minority below.

Company Name:

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