Fillable Printable Certified Payroll Report - Washington Department of Labor and Industries
Fillable Printable Certified Payroll Report - Washington Department of Labor and Industries
Certified Payroll Report - Washington Department of Labor and Industries
F700-065-000 certified payroll report 05-09 Employee Benefits Distribution and Signature Certification on Reverse Side
Department of Labor and Industries
Prevailing Wage Program
PO Box 44540
Olympia WA 98504-4540
(360) 902-5335
CERTIFIED PAYROLL REPORT
Prime Contractor
Project Name
County
Project or Contract#
Subcontractor
Project Address
City
State
For the week ending:
Awarding Agency Name
Phone
Company Name
Phone
Month Day Year
Address
City
State
ZIP+4
Address
City
State
ZIP+4
Work Classification
and
Soc Sec# of Employee
Name
and
Address
Overtime or
Regular
Day and Date
Total
Hours
Rate
of
Pay
Gross Amount
Earned
Total
Hourly
“Usual
Benefits”
Deductions
NET
WAGES
Sun Mon Tue Wed Thu Fri Sat
FICA
Withhold
-ing Tax
Other
Hours Worked Each Day
1.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
2.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
3.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
4.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
5.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
6.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
7.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
8.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
9.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
10.
OT
0.00 0.00
0.00 $ 0.00 $ 0.00
RG
0.00 0.00
F700-065-000 certified payroll report backer 05-09
Department of Labor and Industries
Prevailing Wage Program
PO Box 44540
Olympia WA 98504-4540
AFFIRMATION
Today’s Date
Printed name of party signing this report
Title
The party signing this report pays or supervises the
payment of the persons employed by:
(Name of contractor or subcontractor)
Project Na me :
For the week starting:
For the week ending:
The party signing below AFFIRMS the following:
(1)
All information contained in this Certified Payroll Report, including any addenda, is correct and complete.
(2)
The wage rates for workers, laborers or mechanics as reported above are not less than the applicab le wage rates contained in any wage determination related to the
contract; and the classifications as reported above for each worker, laborer or mechanic conform with the actual work performed by such worker, laborer or mechanic.
(3)
The payments of usual benefits as listed above have been or will be made to appropriate approved plans, funds or programs for the be nefi t of such em pl oy ees.
(4)
All persons employed on the above-referenced project(s) have been paid the full weekly wages earned, and no rebates have been or will be made either d irectly or
indirectly to or on behalf of the above-named contractor or subcontractor from the weekly wages earned by any person. No deductions, other than those which are legally
permissible, have been made by any person either directly or indirectly from the full wages earned.
(5)
Any apprentices employed in the above period are duly registered in a bona fide appr enticeship program registered with the Washington State Apprenticeship and
Training Council.
Falsification of any of the above statements is a violation of RCW 39.12.050 subject to prosecution, sanctions, and penalties.
Print or type name of party signing this report
Title
Signature
“USUAL BENEFITS” DISTRIBUTION (Please report in “per hour” terms)
Work Classification
Total Ho urly
“Usual Benefits”
(A + B + C + D + E)
(A) Hourly Pension (B) Hourly Medical (C) Hourly Vacation (D) Hourly Holiday
(E) Approved
Apprentice Program
1. $ 0.00
2. $ 0.00
3. $ 0.00
4. $ 0.00
5. $ 0.00
6. $ 0.00
7. $ 0.00
8. $ 0.00
9. $ 0.00
10. $ 0.00
