Fillable Printable Certified Payroll - Michigan
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 #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
NAME:
ETH/GEN:
ID #:
GROUP/CLASS #:
S
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
ON
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
I,
(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
o
n
t
he
(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
de
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
xc
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.
(c) E
XC
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)
