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

Hours

Gross

Taxes

OT

OT

OT

OT

OT

OT

OT

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 __________________________