Prevailing_Wage_-_Payroll_Certification_Form_Sample.pdf

[New] In accordance with Section 31-53b(a) of the CG.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 certificd payroll on the project.

In accordance with Connecticut General Statutes, 31-53 PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTSConnecticut Department of Labor

Certified Payrolls with a statement of compliance

Wage and Workplace Standards Division shall be submitted monthl}' to the contracting agency.

WEEKLY PAYROLL200 Foil)' Brook 81vd.

Wethersfield, CT 06109CONTRACTOR NAME AND ADDRESS:

SUBCONTRACTOR NAME & ADDRESSWORKER'S COMPENSATION INSURANCE CARRIER

landon Corporation. 15 Connecticut Avenue, Northford, CT 06472

XYZ Corporation Travelers Insurance Company

2 Main Street

POLICY # #BAC8888928

PA YROLL NUMBER

Week-EndingPROJECT NAME & ADDRESS Yantic, CT 06389

Date

DOT 105-296, Route 82

EFFECTIVE DATE: 1/1/09

9/26/09

EXPIRATION DATE: 12/31/09

PERSON/WORKER,

APPRMALE! WORK DAY AND DATETolal STBASE 1I0URL YTYPE OFGROSS PAYTOTAL DEDUCTIONSGROSS PAY FOR

ADDRESS and SECTION

RATEFEMALECLASSIFICATIONSMTWTIIFSHoursRATEFRINGEFOR ALLFEDERALSTATE THIS PREVAILINGCHECK # AND

AND BENEFITSWORK RATE JOBNET PAY

RACE'

Trade License Type20212223242526 TOTAL FRINGEPer HourPERFORMED LIST

& Number - OSHA

TotalBENEFIT PLANI through 6THIS WEEKFICAWITH-WITH-OTHER

10 Certification Number

HOURS WORKED EACH DAYOff HouCASH(see back) HOLDINGHOLDING

Robert Craft

S-TIMEI. $ 5.80

M/C Electrical Lineman

$ 30.75 #123

81 Maple Street

E-1 123456788888 2 $

$1,582.80 P-xxxx$1,582.80

Owner

Base Rate 3 $ 2.01

Willimantic, CT 06226 OSHA 123456

4. $

$ xxx.xx

O-TIME $ 8.82

5. $

Cash Fringe

6. $

S-TIME

I. $

Ronald Jones 65%MISElectrical 88888 $ 19.992. $$1,464.80 G-xxx#124xx.xx xxx.xxxx.xx $1,464.80 212 Elm Street

Apprentice 40 Norwich, CT 06360

Base Rate

3. $

$xxx.xxOSHA 234567

O-TIME4. $

$ 16.63

5. $ Cash Fringe

6. $

Franklin T. Smith

S-TIMEI. $

MIH

Project Manager 8

#125 234 Washington Rd.

2. $ $1,500.00xx.xxxx.xxxx.xxM-xx.x

8New london. CT

Base Rate3. $

06320

0- TIME4. $ xxx.XX

SECTION B

$5. $

Cash Fringe

6. $

S-TIME

1. $

2. $

Base Rate

3. $

O-TIME

4. $

5. $

Cash Frinl.!e

6 $

7/13/2009

'IF REQUIRED IOF ;:LWWS-CPI

'SEE REVERSE SIDEPAGE NUMBER

OSHA 10 -ATIACH 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 Blue Cross 4) Disability _

2) Pension or retirement 5) Vacation, holiday _

3) Life Insurance Utopia 6) Other (please specify) _

CERTIFIED STATEMENT OF COMPLIANCE

For the week ending date of 9/26/09-----------' I, Robert Craft of XYZ Corporation , (hereafter known as

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

Section A:

I. 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 employee to any e'mployee 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 employee 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 employee of the Employer 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 employee's name first appears.

~~~(Signature) , ow~ (Title)

/o/~-) t/ Cj Submitte6 on (.Date)

Section B: Applies to CONNDOT Projects ONLY That pursuant to CONNDOT contract requirements for reporting purposes only, all employees listed under Section B who performed work on this project are not covered under the prevailing wageRquirements defined in Connecticut General Statutes Section 31-53.

o u/I.../e; " (Title)

Note: CTDOL will assume all hours worked were performed under Section A unless clearly delineated as Section B WWS-CP I as such. Should an employee perform work under both

Section A and Section B, the hours worked and wages paid must be segregated for reporting purposes.

***THIS IS A PUBLIC DOCUMENT***

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

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