Fillable Printable Certified Transcript of Payroll Form - Illinois

Certified Transcript of Payroll Form - Illinois

State of Illinois

Illinois Department of Labor

Certified Transcript of Payroll

IL452CM01

AFFIDAVIT

SUBCONTRACTORS

Weekly Statement of Compliance

Attach explanation of Monies paid, copy of contract

of billing, or other pertinent information.

Date:

(name signatory party)

(Title)

, do

hereby state: that I pay or supervise the payment

of the persons employed on the public works

project

(name of project)

;

that during the payroll period commencing on the

day of

(day)

(month)

(year)

all persons employed on said project have 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

(name of contractor or subcontractor)

from the full weekly wages earned by any person,

and that no deductions have been made either

directly or indirectly from the full weekly wages

earned by any persons, other than permissible

deductions as defined by Federal and/or State

Law. I further certify that this payroll is correct

and complete; that the wage rates contained

therein are not less than the actual rates herein

stated and that the classification set forth for each

laborers or mechanic conform to the work he/she

performed.

Signature

Digital Signature

Company Name:

Contact Person:

(Address)

(City)

(State)

(zipcode)

Telephone Number:

Contact Person:

(Address)

(City)

(State)

(zipcode)

Telephone Number:

Contact Person:

(Address)

(City)

(State)

(zipcode)

Telephone Number:

Contact Person:

(Address)

(City)

(State)

(zipcode)

Telephone Number:

Company Name:

FRINGES

Health Fund

Health Address

Health Sponsor

Health Admin

Pension Admin

Pension Sponsor

Pension Address

Pension Fund

401(k) Admin

401(k) Sponsor

401(k) Address

401(k) Fund

Vacation Admin

Vacation Sponsor

Vacation Address

Vacation Fund