Fillable Printable Certified Payroll Form - Illinois

Certified Payroll Form - Illinois

Certified Payroll

County of Peoria, Illinois

State of Illinois )

) SS

County of Peoria )

_________________________________________________________________________________, being first duly sworn, states under oath that

1. He/She is (

Print Title)_____________________________________________________________________________________________________________________________________of

(Print name of contractor)____________________________________________________________________________________________________________________________________________________________________

And, that he/she has the authority to make this certification on behalf of the above-named contractor. The above-named party, first being duly

sworn, states under oath:

2. That: Payroll records attached to this certification are true, complete, and

accurate payroll records for all workers employed by the above-named contractor

during the period of:

_________________________________________to_____________________________________ for the

_________________________________________________________________________________Project; and,

3. That: The hourly rate paid to each worker is not less than the general prevailing

rate of hourly wages (base salary and fringes by category) required by the

Prevailing Wage Act (820 ILCS 130 et.seq.), as determined by the Illinois

Department of Labor for Peoria County, IL; and,

4. That: All persons employed on said project have been paid the full weekly wages

earned; that no rebates have been or will be made either directly or indirectly to or

on behalf of said contractor.

5. That: Both I and the above-named contractor are aware that filing a Certified

Payroll we know to be false is a Class A Misdemeanor; and,

6. That: Any apprentices employed in the above period are duly registered in a

bona fide apprenticeship program registered with a State apprenticeship agency

recognized by the Bureau of Apprenticeship and Training, United States Department

of Labor. Apprentices not duly registered in a bona fide apprenticeship program

are, for the purposes of Prevailing Wage in a Public Works Project, eligible for the

full salary and fringe benefits specified by the State of Illinois Department of Labor

each month for the County of Peoria. Program Sponsors of Apprentices who are

duly registered in a bona fide apprenticeship program will provide the reduced

wage and fringe benefit requirements to contractors and subcontractors to attach to

this Certified Payroll.

Public Works projects over five thousand dollars ($5,000) are required to have the

above-described Apprenticeship Program in Peoria County.

7 That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,

FUNDS, OR PROGRAMS less than the State of Illinois Department of Labor-

specified amounts:

___In addition to the basic hourly wage rates paid to each laborer or mechanic

listed in the above-referenced payroll, payments of fringe benefits as listed in

the Department of Labor specified rates have been made to appropriate

programs or employees for the benefit of such employees. (report "F" for fund,

"E" for amounts paid employees)

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH Each laborer or

mechanic listed in the above referenced payroll has been paid, as indicated on

the payroll, an amount not less than the sum of the applicable basic hourly wage

rate plus the amount of the required fringe benefits as specified by category or

aggregate, by the Department of Labor, State of Illinois, except as noted in

Section 7(c) below:

Signed: __________________________________________________________________________________

____________________________________________________________________________________________

(Print name and title)

Subscribed and sworn before me on this

__________ day of ____________________________, 20____

_______________________________________________________

Notary Public (SEAL)

Insert 7(c) Exceptions if any: