- Certified Payroll Form - Minnesota Department of Labor and Industry
- Certified Payroll Report - Ohio
- Weekly Payroll Records Report and Statement of Compliance - Massachusetts
- Certified Payroll - Michigan Department of Transportation
- Statement of Compliance - California
- Certification of Payroll by Officer - New York
Fillable Printable Certified Payroll - Michigan Department of Transportation
Fillable Printable Certified Payroll - Michigan Department of Transportation
Certified Payroll - Michigan Department of Transportation
(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
C
ERTIFIED 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 of
$672.49
$714.21
$603.59
6
W/M
22.00
0
$196.41
0
Sun
0
$88.21
Operator
J
Laborer
A1
Laborer
Electrician
0
3.15
0
0
1.75
$384.00
8
$194.00
0
11/28
0
$1.70
0
O
$0.00
$880.00
Lansing, MI
16
6
40
6
B/F
0
$109.01
11/27
$1.64
11/25
11/26
11/23
11/24
11/22
8
Stable Work 2904
8
33.00
$0.00
0
Mon
6
0
$84.47
2.00
0
Wacki, Bill
2
8
$896.50
Ritz, Jes
0
Tue
$207.51
0
8
1
$11.79
$111.47
6
11/28/2010
0
$12.83
3333
2222
2
4444
0
Wed
30.00
0
W/M
8
1.5
Points North (CPW Sample Reports) (contractor)
Hiko, Lee
$0.00
8
0
$800.00
22.00
16.00
1.5
0
Thu
$306.40
0
O
2.50
2
16
$34.21
42
8
0
$147.00
0
9999
0
0
0
Fri
A/M
0
Lew, Matt
1
$24.56
$1.72
$27.52
0
$0.00
20.00
2.00
1.75
371 Canal Park Dr
Lansing, MI 48901
$182.29
LOCAL
TAX
0
Sat
0
$1035.50
0
$27.02
$67.32
$68.58
$61.20
$29.38
$295.79
Date
I,
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
o
n
t
he
(Contractor or Subcontractor)
; that during the payroll period commencing 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 made either directly or indirectly to or on behalf of said
from the full
(Contractor or Subcontractor)
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and described 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 for laborers or mechanics contained therein are not less than the
applicable wage rates contained in any wage determination incorporated into the contract; that the
classifications set forth therein for each laborer or mechanic conform with the work he performed.
(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
Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a
State, are registered with the Bureau of Apprenticeship and Training, United States Department 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 l
a
borer 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 reference
d 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 FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
Page of
MDOT CP-347 (04/10)
Owner
Owner
22
November
28
John Smith
John Smith
November
2
2
2010
Points North (CPW Sample Reports)
Points North (CPW Sample Reports)
Stable Work 2904
2010
5/16/2011
