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Fillable Printable Certified Transcript of Payroll Form - Illinois

Fillable Printable Certified Transcript of Payroll Form - Illinois

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:
I,
,
, do
hereby state: that I pay or supervise the payment
of the persons employed on the public works
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:
Company Name:
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
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