Prevailing Wage Payroll Report Form~73.pdf

87 KB Posted

Attached to
DRM 2024-57 #7 Emergency Notification System at MCI-Shirley and SBCC
Solicitation number
BD-25-1025-DOCFS-9843-111147
Issued by
Worcester County, Massachusetts

About this file

Written by GovTribe AI ·

This is a Massachusetts Weekly Certified Payroll Report Form used for public works projects in Massachusetts. The form is a standard document that contractors and subcontractors must submit to report employee wages and benefits on public works projects. It requires detailed information including company details, contract information, awarding authority information, project location, and minimum wage rate sheet numbers.

The form includes fields for tracking employee information, work classifications, OSHA 10 certification status, apprenticeship rates, and detailed hourly breakdowns of wages and benefits. It requires documentation of base wages, health and welfare insurance contributions, ERISA pension plans, and other fringe benefits. The form specifically requires verification of apprentice registration with MA DLS's Division of Apprentice Standards and mandates that contractors submit true and accurate copies to the awarding authority by first-class mail or email, accompanied by a statement of compliance. Non-compliance may result in criminal action or civil citation.

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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 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
Text4:
Text5:
Text6:
Text7:
Text8:
Text9:
Text10:
Text11:
Text12:
Text13:

File details come from the government source that posted it. Updated .