CertifiedPayroll.pdf

PDF 128 KB Posted

Attached to
Repair of Fire Suppression Tank Nut Island Headworks
Solicitation number
S122707-vCurrent
Issued by
Norfolk County, Quincy City, Massachusetts

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This document is a Massachusetts Weekly Certified Payroll Report Form that must be submitted by contractors and subcontractors working on a public works project. The form requires reporting of employee names, work classifications, hours worked, hourly wages, and fringe benefit contributions. The project details included are the Awarding Authority's name, Public Works Project Name and Location, and Contract Number. Contractors must submit this report weekly to the Awarding Authority, and failure to comply may result in criminal or civil penalties.

The form allows for reporting of multiple employees across multiple work weeks. Key details required include regular and overtime hours worked, base hourly wage, and fringe benefit contributions for health, pension, and unemployment insurance. Apprentice wage rates are also noted. The form must be signed by the employer with their title and taxpayer ID number provided.

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MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM

Company's Name: Address: Phone No.: Payroll No.:

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

Awarding Authority's Name: Public Works Project Name: Public Works Project Location: Min. Wage Rate Sheet No.

General / Prime Contractor's Name: Subcontractor's Name: "Employer" Hourly Fringe Benefit Contributions

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

Employee Name & Complete Address

Employee is

OSHA 10

Certified (?) Work Classification:

Appr.

Rate (%) Su. Mo. Tu. We. Th. Fr. Sa.

All Other Hours

Hourly Base Wage

(B)

Health & Welfare

Insurance (C')

ERISA

Pension Plan

(D)

Supp.

Unemp.

(E)

Total Hourly Prev. Wage

(F) Total Gross

Wages Check No.

(H)

Pursuant to MGL Ch. 149 s.27B, every contractor and subcontractor is required to submit a "true and accurate" copy of their weekly payroll records directly NOTE:

to the awarding authority. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.

Date recieved by awarding authority

Page of / /

Hours Worked

Project Gross Wages

(G)

Project Hours

(A)

Draft 2

Companys Name:, Row 1:
Address:, Row 1:
Phone No:, Row 1:
Payroll No:, Row 1:
Employers Signature:, Row 1:
Title:, Row 1:
Contract No:, Row 1:
Tax Payer ID No, Row 1:
Work Week Ending:, Row 1:
Awarding Authoritys Name:, Row 1:
Public Works Project Name:, Row 1:
Public Works Project Location:, Row 1:
Min Wage Rate Sheet No, Row 1:
General Prime Contractors Name:, Row 1:
Subcontractors Name:, Row 1:
Su, Row 2:
Mo, Row 2:
Tu, Row 2:
We, Row 2:
Th, Row 2:
Fr, Row 2:
Sa, Row 2:
Work Classification:, Row 1:
Su, Row 1:
Mo, Row 1:
Tu, Row 1:
We, Row 1:
Th, Row 1:
Fr, Row 1:
Sa, Row 1:
Work Classification:, Row 2:
Su, Row 3:
Mo, Row 3:
Tu, Row 3:
We, Row 3:
Th, Row 3:
Fr, Row 3:
Sa, Row 3:
Su, Row 4:
Mo, Row 4:
Tu, Row 4:
We, Row 4:
Th, Row 4:
Fr, Row 4:
Sa, Row 4:
Work Classification:, Row 3:
Su, Row 5:
Mo, Row 5:
Tu, Row 5:
We, Row 5:
Th, Row 5:
Fr, Row 5:
Sa, Row 5:
Su, Row 6:
Mo, Row 6:
Tu, Row 6:
We, Row 6:
Th, Row 6:
Fr, Row 6:
Sa, Row 6:
Work Classification:, Row 4:
Su, Row 7:
Mo, Row 7:
Tu, Row 7:
We, Row 7:
Th, Row 7:
Fr, Row 7:
Sa, Row 7:
Su, Row 8:
Mo, Row 8:
Tu, Row 8:
We, Row 8:
Th, Row 8:
Fr, Row 8:
Sa, Row 8:
Work Classification:, Row 5:
Su, Row 9:
Mo, Row 9:
Tu, Row 9:
We, Row 9:
Th, Row 9:
Fr, Row 9:
Sa, Row 9:
Su, Row 10:
Mo, Row 10:
Tu, Row 10:
We, Row 10:
Th, Row 10:
Fr, Row 10:
Sa, Row 10:
Work Classification:, Row 6:
Su, Row 11:
Mo, Row 11:
Tu, Row 11:
We, Row 11:
Th, Row 11:
Fr, Row 11:
Sa, Row 11:
Su, Row 12:
Mo, Row 12:
Tu, Row 12:
We, Row 12:
Th, Row 12:
Fr, Row 12:
Sa, Row 12:
Work Classification:, Row 7:
Su, Row 13:
Mo, Row 13:
Tu, Row 13:
We, Row 13:
Th, Row 13:
Fr, Row 13:
Sa, Row 13:
Su, Row 14:
Mo, Row 14:
Tu, Row 14:
We, Row 14:
Th, Row 14:
Fr, Row 14:
Sa, Row 14:
Date recieved by awarding authority:
Apprentice Rate - Row 4:
Apprentice Rate - Row 5:
Apprentice Rate - Row 6:
Apprentice Rate - Row 7:
C3:
C2:
D7:
D6:
D5:
D4:
D3:
D2:
D1:
B2:
B3:
B4:
B5:
B6:
B7:
H7:
H6:
H5:
H4:
H3:
H2:
H1:
A1 - Project Hours, Row 1:
A2 - Project Hours, Row 2:
A3 - Project Hours, Row 3:
A4 - Project Hours, Row 4:
A5 - Project Hours, Row 5:
A6 - Project Hours, Row 6:
A7 - Project Hours, Row 7:
All Other Hours, Row 1:
All Other Hours, Row 2:
All Other Hours, Row 3:
All Other Hours, Row 4:
All Other Hours, Row 5:
All Other Hours, Row 6:
All Other Hours, Row 7:
G1 - Project Gross Wages, Row 1:
G2 - Project Gross Wages, Row 2:
G3 - Project Gross Wages, Row 3:
G4 - Project Gross Wages, Row 4:
G5 - Project Gross Wages, Row 5:
G6 - Project Gross Wages, Row 6:
G7 - Project Gross Wages, Row 7:
Total Gross Wages, Row 1:
Total Gross Wages, Row 2:
Total Gross Wages, Row 3:
Total Gross Wages, Row 4:
Total Gross Wages, Row 5:
Total Gross Wages, Row 6:
Total Gross Wages, Row 7:
Employee Name & Complete Address, Row 3:
Employee Name & Complete Address, Row 2:
Employee Name & Complete Address, Row 1:
Employee Name & Complete Address, Row 4:
Employee Name & Complete Address, Row 7:
Employee Name & Complete Address, Row 6:
Employee Name & Complete Address, Row 5:
Apprentice Rate - Row 1:
Apprentice Rate - Row 2:
Apprentice Rate - Row 3:
B1:
C1:
E1:
C4:
C6:
E2:
E4:
E5:
E6:
E7:
F1:
F2:
F3:
F4:
F5:
F6:
F7:
E3:
C7:
Check Box205: Off
Check Box206: Off
Check Box207: Off
Check Box208: Off
Check Box209: Off
Check Box210: Off
Check Box211: Off
C5:

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