Fillable Printable Certified Payroll - Michigan

Certified Payroll - Michigan

(1) NAME OF CONTRACTOR / SUBCONTRACTOR (CIRCLE ONE) (2) ADDRESS

(3) PAYROLL NO. (4) FOR WEEK ENDING (5) PROJECT AND LOCATION (6) CONTRACT ID

(b) (c) (e) (f) (g) (h) (i) (k)

NAME:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

NAME:

ETH/GEN:

ID #:

GROUP/CLASS #:

MICHIGAN DEPARTMENT OF TRANSPORTATION

CERTIFIED PAYROLL

COMPLETION OF CERTIFIED PAYROLL FORM FULFILLS THE MINIMUM MDOT PREVAILING WAGE REQUIREMENTS

ETH/GEN:

PROJECT

RATE OF

FRINGE

PAY

Hour Type

PROJECT

RATE OF

PAY

(d) DAY AND DATE

TOTAL

WEEKLY

WAGES

PAID FOR

ALL JOBS

OTHER

TOTAL

DEDUCT

(a)

EMPLOYEE INFORMATION

HOURS WORKED ON PROJECT

TOTAL

HOURS

PROJECT

WORK CLASSIFICATION

TOTAL

WEEKLY

HOURS

WORKED

ALL JOBS

FEDERAL

STATE

(j) DEDUCTIONS

FICA

GROSS

PROJECT

EARNED

GROSS

WEEKLY

EARNED

Michigan Department

Of Transportation

CP-347 (

04/10)

Page 1 of 2

Date

(Name of Signatory Party) (Title)

do hereby state:

(1) That I pay or supervise t he payment of t he pers ons em ployed by

(Contractor or Subcontractor)

; that during the payroll period commenc ing on the

(Building or Work)

day of , , and ending the day of , ,

all persons employed on said project hav

e been paid the full weekly wages earned, that no rebates have

been or will be m ade eit her direc t ly or indirect ly to or on behalf of s aid

from the full

(Contractor or Subcontractor)

weekly wages earned by any person and that no deductions have been made either directly or indirectly

from t he f ull wages earned by any person, other t han perm is s ible deduc t ions as defined in Regulations, Part

3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act , as am ended (48 Stat. 948,

63 Start. 108, 72 St at . 967; 76 St at . 357; 40 U.S. C. § 3145 ), and des c ribed below:

(2) That

any payrolls otherwise under t

his contract required to be submitted for the above period are

correct and complete; that the wage rates f or laborers or mechanics contained therein are not les s than the

applicable wage rates contained in any wage determination incorporated into the contract; that the

class if ic at ions s et f ort h t herein f or eac h laborer or m ec hanic c onf orm with the work he perform ed.

(3) That any apprentices employed in the above period are duly registered in a bona fi

apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of

Apprentices hip and Training, United St at es Departm ent of Labor, or if no s uc h rec ognized agency exists in a

State, are regis t ered with the Bureau of Apprent ic es hip and Training, United St at es Departm ent of Labor.

(4) That:

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

−

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

the above referenced payroll, payments of fringe bene

fits as listed in the contract

have been or will be made to appropriate programs for the benefit of such

employees, e

ept as noted in section 4(c) below.

(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 listed

in the contract, except as noted in section 4(c) below.

EPTIONS

REMARKS:

EXCEPTION (CRAFT)

EXPLANATION

NAME AND TITLE SIGNATURE

THE WILLFUL FAL

SIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR

SUBCONTRACTOR T O CIVI L OR CRIMINAL PROSECUT ION. SEE SECT ION 1001 OF TITLE 18 AND SECTION 231 OF TITLE

31 OF THE UNIT ED STATES CODE.

Page 2 of 2

MDOT CP-347 (

04/10)