Prevailing Wage Payroll Report Form~70.pdf
PDF 87 KB Posted
- Attached to
- DRM 2024-57 #4 Emergency Notification System
- Solicitation number
- BD-25-1025-DOCFS-9816-108849
- Issued by
- Norfolk County, Massachusetts
About this file
This document is a Massachusetts Weekly Certified Payroll Report Form for a public works project. The form includes details such as the company's name, address, and tax ID number, as well as the contract number, work week ending date, and the name and location of the public works project. The form requires the employer to provide information about each employee, including their name, work classification, hours worked, hourly base wage, and total fringe benefit contributions. The form also includes a section for the employer to certify that all apprentice employees are currently registered with the Massachusetts Department of Labor Standards' Division of Apprentice Standards.
The document outlines the reporting requirements for contractors and subcontractors working on the public works project, including the need to submit a true and accurate copy of the certified weekly payroll records to the awarding authority. Failure to comply with these requirements may result in the commencement of a criminal action or the issuance of a civil citation.
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Text version
MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Company's Name: Address: Phone No.: Payroll No.:
Employer's Signature: Title: Contract No: Tax Payer ID Number Work Week Ending:
Awarding Authority's Name: Public Works Project Name: Public Works Project Location: Min. Wage Rate Sheet Number
General / Prime Contractor's Name: Subcontractor's Name: "Employer" Hourly Fringe Benefit Contributions
(B+C+D+E) (A x F)
Employee Name & Complete Address
Work Classification:
Employee is OSHA certified
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)
Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards? YES NO
No apprentices are identified above
Date Received by Awarding Authority
Page ________of________ / /
NOTE: 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.
For all apprentices performing work during the reporting period, attach a copy of the apprentice identification card issued by the Massachusetts Department of Labor Standards / Division of Apprentice Standards.
Hours Worked Project Gross Wages
Project Hours
(A)
| Companys NameRow1: |
| AddressRow1: |
| Phone NoRow1: |
| Payroll NoRow1: |
| Employers SignatureRow1: |
| TitleRow1: |
| Contract NoRow1: |
| Tax Payer ID NumberRow1: |
| Work Week EndingRow1: |
| Awarding Authoritys NameRow1: |
| Public Works Project NameRow1: |
| Public Works Project LocationRow1: |
| Min Wage Rate Sheet NumberRow1: |
| General Prime Contractors NameRow1: |
| Subcontractors NameRow1: |
| undefined_2: |
| Employee Name Complete AddressRow1: |
| Work ClassificationRow1: |
| SuRow1: |
| MoRow1: |
| TuRow1: |
| WeRow1: |
| ThRow1: |
| FrRow1: |
| SaRow1: |
| All Other Hours Project Hours ARow1: |
| SuRow2: |
| MoRow2: |
| TuRow2: |
| WeRow2: |
| ThRow2: |
| FrRow2: |
| SaRow2: |
| All Other Hours Project Hours ARow2: |
| Hourly Base Wage BRow1: |
| Total Gross Wages Project Gross WagesRow1: |
| Health Welfare Insurance CRow1: |
| ERISA Pension Plan DRow1: |
| Supp Unemp ERow1: |
| Total Hourly Prev Wage FRow1: |
| Total Gross Wages Project Gross WagesRow2: |
| Check No HRow1: |
| Employee Name Complete AddressRow2: |
| Work ClassificationRow2: |
| undefined_3: |
| SuRow3: |
| MoRow3: |
| TuRow3: |
| WeRow3: |
| ThRow3: |
| FrRow3: |
| SaRow3: |
| All Other Hours Project Hours ARow3: |
| SuRow4: |
| MoRow4: |
| TuRow4: |
| WeRow4: |
| ThRow4: |
| FrRow4: |
| SaRow4: |
| All Other Hours Project Hours ARow4: |
| Hourly Base Wage BRow2: |
| Total Gross Wages Project Gross WagesRow3: |
| Health Welfare Insurance CRow2: |
| ERISA Pension Plan DRow2: |
| Supp Unemp ERow2: |
| Total Hourly Prev Wage FRow2: |
| Total Gross Wages Project Gross WagesRow4: |
| Check No HRow2: |
| Employee Name Complete AddressRow3: |
| Work ClassificationRow3: |
| undefined_4: |
| SuRow5: |
| MoRow5: |
| TuRow5: |
| WeRow5: |
| ThRow5: |
| FrRow5: |
| SaRow5: |
| All Other Hours Project Hours ARow5: |
| SuRow6: |
| MoRow6: |
| TuRow6: |
| WeRow6: |
| ThRow6: |
| FrRow6: |
| SaRow6: |
| All Other Hours Project Hours ARow6: |
| Hourly Base Wage BRow3: |
| Total Gross Wages Project Gross WagesRow5: |
| Health Welfare Insurance CRow3: |
| ERISA Pension Plan DRow3: |
| Supp Unemp ERow3: |
| Total Hourly Prev Wage FRow3: |
| Total Gross Wages Project Gross WagesRow6: |
| Check No HRow3: |
| Employee Name Complete AddressRow4: |
| Work ClassificationRow4: |
| undefined_5: |
| SuRow7: |
| MoRow7: |
| TuRow7: |
| WeRow7: |
| ThRow7: |
| FrRow7: |
| SaRow7: |
| All Other Hours Project Hours ARow7: |
| SuRow8: |
| MoRow8: |
| TuRow8: |
| WeRow8: |
| ThRow8: |
| FrRow8: |
| SaRow8: |
| All Other Hours Project Hours ARow8: |
| Hourly Base Wage BRow4: |
| Total Gross Wages Project Gross WagesRow7: |
| Health Welfare Insurance CRow4: |
| ERISA Pension Plan DRow4: |
| Supp Unemp ERow4: |
| Total Hourly Prev Wage FRow4: |
| Total Gross Wages Project Gross WagesRow8: |
| Check No HRow4: |
| Employee Name Complete AddressRow5: |
| Work ClassificationRow5: |
| undefined_6: |
| SuRow9: |
| MoRow9: |
| TuRow9: |
| WeRow9: |
| ThRow9: |
| FrRow9: |
| SaRow9: |
| All Other Hours Project Hours ARow9: |
| SuRow10: |
| MoRow10: |
| TuRow10: |
| WeRow10: |
| ThRow10: |
| FrRow10: |
| SaRow10: |
| All Other Hours Project Hours ARow10: |
| Hourly Base Wage BRow5: |
| Total Gross Wages Project Gross WagesRow9: |
| Health Welfare Insurance CRow5: |
| ERISA Pension Plan DRow5: |
| Supp Unemp ERow5: |
| Total Hourly Prev Wage FRow5: |
| Total Gross Wages Project Gross WagesRow10: |
| Check No HRow5: |
| Employee Name Complete AddressRow6: |
| Work ClassificationRow6: |
| undefined_7: |
| SuRow11: |
| MoRow11: |
| TuRow11: |
| WeRow11: |
| ThRow11: |
| FrRow11: |
| SaRow11: |
| All Other Hours Project Hours ARow11: |
| SuRow12: |
| MoRow12: |
| TuRow12: |
| WeRow12: |
| ThRow12: |
| FrRow12: |
| SaRow12: |
| All Other Hours Project Hours ARow12: |
| Hourly Base Wage BRow6: |
| Total Gross Wages Project Gross WagesRow11: |
| Health Welfare Insurance CRow6: |
| ERISA Pension Plan DRow6: |
| Supp Unemp ERow6: |
| Total Hourly Prev Wage FRow6: |
| Total Gross Wages Project Gross WagesRow12: |
| Check No HRow6: |
| Employee Name Complete AddressRow7: |
| Work ClassificationRow7: |
| undefined_8: |
| SuRow13: |
| MoRow13: |
| TuRow13: |
| WeRow13: |
| ThRow13: |
| FrRow13: |
| SaRow13: |
| All Other Hours Project Hours ARow13: |
| SuRow14: |
| MoRow14: |
| TuRow14: |
| WeRow14: |
| ThRow14: |
| FrRow14: |
| SaRow14: |
| All Other Hours Project Hours ARow14: |
| Hourly Base Wage BRow7: |
| Total Gross Wages Project Gross WagesRow13: |
| Health Welfare Insurance CRow7: |
| ERISA Pension Plan DRow7: |
| Supp Unemp ERow7: |
| Total Hourly Prev Wage FRow7: |
| Total Gross Wages Project Gross WagesRow14: |
| Check No HRow7: |
| No apprentices are identified above: |
| commencement of a criminal action or the issuance of a civil citation: |
| of: |
| Check Box2: Off |
| Check Box3: Off |
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