Fillable Printable Certified Payroll Report Form - Ohio

Certified Payroll Report Form - Ohio

CERTIFIED PAYROLL REPORT

CONTRACTING PUBLIC AUTHORITYPROJECT NAME AND LOCATIONNAME OF GENERAL/PRIME CONTRACTOREmployer Name and Address

Project NumberPage of Payroll #Week EndingCheck if Subcontractor

1211109. Total8. Total7. Fringes654321. Employee Name, Address,

Net OtherTaxesGrossHoursCash Approved Plans ProjectBaseProjectHours WorkedWork SS#

PaidDeductsWithheldAll JobsAll JobsCash & Approved Plans GrossRateTotal Hrs.Day & DateClass

OtherAppVac.Pens.H & W

Date My signature on this form signifies that I pay, or supervise the payment of the employees shown above. I am certifying: 1) That during the pay period reported on this form,

all hours worked on this project have been paid at the appropriate prevailing wage rate for the class of work done. 2) That fringe benefits have been paid as indicated above. 3) That no rebates or deductions

have been or will be made,directly or indirectly from the total wages earned, other than permissible deductions as defined in the Ohio Revised Code Chapter 4115. 4) That apprentices are registered with the

U.S. Department of Labor Bureau of Apprenticeship and Training. The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.

SignatureName and Title

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