Prevailing_Wage_-_Payroll_Certification_Form.pdf

[New] In accordance with Section 31-53b(a) of the C.G.S. each contractor shall provide a copy of the OSHA 10 Hour Construction Safety and Health Card for each employee, to be attached to the first certified payroll on the project.

In accordance with Connecticut General Statutes, 31-53 PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS Connecticut Department of Labor Certified Payrolls with a statement of compliance Wage and Workplace Standards Division shall be submitted monthly to the contracting agency. WEEKLY PAYROLL 200 Folly Brook Blvd.

Wethersfield, CT 06109 CONTRACTOR NAME AND ADDRESS: SUBCONTRACTOR NAME & ADDRESS WORKER'S COMPENSATION INSURANCE CARRIER

POLICY #

PAYROLL NUMBER Week-Ending PROJECT NAME & ADDRESS

Date EFFECTIVE DATE:

EXPIRATION DATE:

PERSON/WORKER, APPR MALE/ WORK DAY AND DATE Total ST BASE HOURLY TYPE OF GROSS PAY TOTAL DEDUCTIONS GROSS PAY FOR ADDRESS and SECTION RATE FEMALE CLASSIFICATION S M T W TH F S Hours RATE FRINGE FOR ALL FEDERAL STATE THIS PREVAILING CHECK # AND

% AND BENEFITS WORK RATE JOB NET PAY

RACE* Trade License Type TOTAL FRINGE Per Hour PERFORMED LIST

& Number - OSHA Total BENEFIT PLAN 1 through 6 THIS WEEK FICA WITH- WITH- OTHER 10 Certification Number HOURS WORKED EACH DAY O/T Hours CASH (see back) HOLDING HOLDING

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $

Cash Fringe 6. $

1. $

$ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

12/9/2013 *IF REQUIRED

WWS-CP1 *SEE REVERSE SIDE PAGE NUMBER OF

OSHA 10 ~ATTACH CARD TO 1ST CERTIFIED PAYROLL

*FRINGE BENEFITS EXPLANATION (P):

Bona fide benefits paid to approved plans, funds or programs, except those required by Federal or State

Law (unemployment tax, worker’s compensation, income taxes, etc.).

Please specify the type of benefits provided:

1) Medical or hospital care 4) Disability

2) Pension or retirement 5) Vacation, holiday

3) Life Insurance 6) Other (please specify)

CERTIFIED STATEMENT OF COMPLIANCE

For the week ending date of , I, of , (hereafter known as

Employer) in my capacity as (title) do hereby certify and state:

Section A:

1. All persons employed on said project have been paid the full weekly wages earned by them during the week in accordance with Connecticut General Statutes, section 31-53, as amended. Further, I hereby certify and state the following:

a) The records submitted are true and accurate;

b) The rate of wages paid to each mechanic, laborer or workman and the amount of payment or contributions paid or payable on behalf of each such person to any employee welfare fund, as defined in Connecticut General Statutes, section 31-53 (h), are not less than the prevailing rate of wages and the amount of payment or contributions paid or payable on behalf of each such person to any employee welfare fund, as determined by the Labor Commissioner pursuant to subsection Connecticut General Statutes, section 31-53 (d), and said wages and benefits are not less than those which may also be required by contract;

c) The Employer has complied with all of the provisions in Connecticut General Statutes, section 31-53 (and Section 31-54 if applicable for state highway construction);

d) Each such person is covered by a worker’s compensation insurance policy for the duration of his employment which proof of coverage has been provided to the contracting agency;

e) The Employer does not receive kickbacks, which means any money, fee, commission, credit, gift, gratuity, thing of value, or compensation of any kind which is provided directly or indirectly, to any prime contractor, prime contractor employee, subcontractor, or subcontractor employee for the purpose of improperly obtaining or rewarding favorable treatment in connection with a prime contract or in connection with a prime contractor in connection with a subcontractor relating to a prime contractor; and

f) The Employer is aware that filing a certified payroll which he knows to be false is a class D felony for which the employer may be fined up to five thousand dollars, imprisoned for up to five years or both.

2. OSHA~The employer shall affix a copy of the construction safety course, program or training completion document to the certified payroll required to be submitted to the contracting agency for this project on which such persons name first appears.

(Signature) (Title) Submitted on (Date)

***THIS IS A PUBLIC DOCUMENT***

***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***

Weekly Payroll Certification For PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS Week-Ending Date:

Public Works Projects (Continued) Contractor or Subcontractor Business Name:

WEEKLY PAYROLL

PERSON/WORKER, APPR MALE/ WORK DAY AND DATE Total ST BASE HOURLY TYPE OF GROSS PAY TOTAL DEDUCTIONS GROSS PAY FOR ADDRESS and SECTION RATE FEMALE CLASSIFICATION S M T W TH F S Hours RATE FRINGE FOR ALL WORK FEDERAL STATE THIS PREVAILING CHECK # AND

% AND BENEFITS PERFORMED RATE JOB NET PAY

RACE* Trade License Type TOTAL FRINGE Per Hour THIS WEEK

& Number - OSHA Total BENEFIT PLAN 1 through 6 FICA WITH- WITH- OTHER 10 Certification Number HOURS WORKED EACH DAY O/T Hours CASH (see back) HOLDING HOLDING

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

1. $ $ 2. $ Base Rate 3. $

4. $ $ 5. $ Cash Fringe 6. $

*IF REQUIRED

12/9/2013 WWS-CP2 NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE (FORM # WWS-CP1) PAGE NUMBER OF