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Fillable Printable Certified Payroll Report - Ohio

Fillable Printable Certified Payroll Report - Ohio

Certified Payroll Report - Ohio

Certified Payroll Report - Ohio

CERTIFIED PAYROLL REPORT
Employer Name & Address
Check if subcontractor
Name of General / Prime Contractor
Project Name & Location Contracting Public Authority
Week Ending
Payroll #
Page_______Of________
Project Number
1. Employee Name, Address
and Social Security Number
2.
Work
Class
3. Hours Worked - Day & Date
4.
Project
Total Hrs.
5.
Base
Rate
6.
Project
Gross
7. Fringes:
Cash
Approved Plans
Cash & Approved Plans
8. Total
Hours
All Jobs
9. Total
Gross
All Jobs
10.
Taxes
Withheld
11.
Other
Deducts
12.
NET
Paid
OT
OT
OT
OT
OT
OT
OT
OT
ST
ST
ST
ST
ST
ST
ST
ST
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 the 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 permissable 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.
Name and Title __________________________
Signature __________________________
H&W Pens Vac App Other
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