Fillable Printable Certified Weekly Payroll Report - New Jersey
Fillable Printable Certified Weekly Payroll Report - New Jersey
Certified Weekly Payroll Report - New Jersey
NAME:
ADDRESS:
CITY: ST
PHONE:
EMAIL:
//
mm dd
ST
year
PAYROLL PERIOD ENDING DATE:
FICA
Total
Fringe
Benefit
Cost/Hr.
With-
holding Tax
HOURS WORKED EACH DAY
Total
Deductions
Net Pa y
Address
City, State, Zip
Trade
PLEASE SPECIFY DAY AND DATE
Total
Hours
Rate of
Pay
Gross
Weekly
Pay
ZIP
Employee Name
CERTIFIED WEEKLY PAYROLL REPORT (REVISED 01/2014)
EDA PW Form 4
NEW JERSEY ECONOMIC DEVELOPMENT A UTHORITY
COUNTY:
The inf o rmation b elo w must b e submitted to the NJEDA pu rsuant to N.J.A.C. 19 :3 0 -3. 5 -9 an d N.J.A.C. 19:30-4.4
PROJECT INFORMATION CONTRACTOR INFORMATION
SEND COMPLETED FORMS TO:
NJED
A
24 Commerce Street - Suite 301 - Intern al Process Managemen
t
N
ewark, NJ 07102 / Office # 973-855-3447 / affirmativ[email protected]
m
MUNICIPALITY:
NJEDA PROJECT NUM BER:
PROJECT NAME:
Overtime (OT) or
Straight Time (ST)
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
O
T
O
EDA Form PW-4 (page 1)
Date ( C ) FRINGE BENEFITS
I,
do hereby certify:
(1) That I pay or supervise the payment of the person(s) employed by
on the
; t hat duri ng the p ayroll p eri od commencing on the
day of , 20 and ending the , day of 20 ,
all persons employed on said project have been paid the full week ly wages earned, that no rebates
have been or will be ma de either directly or indirectly to or on behalf of said
(Project Name)
(Name of signatory party)
NEW JERSEY ECONOMIC DEVELOPMENT AUTHOR ITY
CERTIFIED WEEKLY PAYROLL REPORT (REVISED 01/2014)
EXCEPTION (CRAFT) EXPLANATION
(Title)
(Contractor or Subcontractor)
EDA Form PW-4 (page 2)
(Contractor or Subcontractor)
from the full weekly wages earned by any person and that no deduct ions have been made either direc tly or indirec tly
from the full wages earned by any person, other than permissib le deduc tions as defined in the New Jersey Pr evailing
Wage Act, N.J.S.A. 34:11-56.25 et seq. and Regulation N.J.A.C. 12:60 et seq. and the Payment of Wages Law,
N J S A 34:11 4 1 et seq
PLEASE SPECIFY THE TYPE OF BENEFIT PROVIDED AND NOTE THE TOTAL
COST PER HOUR IN THE FRINGE BENEFIT BOX ON PAGE 1
*
REMARKS
1) Medical or hospital coverage
2) Dental coverage
(2) 3) Pension or Retirement
4) Vacation, Holidays
5) Sick days
6) Life Insurance
7) Other Explain: ___________________
(3) That any appren tices employed in the above period are duly registered in good standing,
(5) N.J.A.C. 19:30-3.5-9 and 4.4 The contractors shall submit
(4) That:
(a) WHERE FRINGE BENEFITS ARE P AID TO APP ROVED PLANS, FUNDS, OR PROGRAM S
(b ) WHERE FRINGE B ENEFITS ARE P AID IN CASH
period are correct and comp lete; that the wage rates for laborers or mech anics con tained therein are not
less than th e applicable wage rates contained in any wage determination in co rporated in to the contract;
that the classification s set forth therein for each laborer or mech anic conform with the work perf ormed
* TO CALCULATE THE C OST PER HOUR, DIVIDE 2, 000 HOURS INTO THE
BENEFIT COST PER YEAR PER EMPLOYEE
in a program approved or certified by the Division of Vocational Education apprenticeship in the New
Jersey Department of Education or by the Bureau of Apprenticeship Training in the United States
Department of Labor.
THE FALSIFICATION OF ANY OF THE ABOVE STATEMENT MAY SUBJECT
THE CONTRACTOR OR SUBC ONTRACTOR TO CIVIL OR C RIM IN AL
PROSECUTION. N.J.S.A. 34:1B-1 et seq., and P.L. 1963, c. 150 - N.J.S.A. 34:11-
56.25 et seq. and provided by Sections 11 through 16, inclusive, of P.L. 1963, c.
150 - N.J.S.A. 34:11-56.35 - 34:11-56.40
SIGNATURENAME AND TITLE
Each labo rer o r mech anic listed in the above ref erenced payroll has been paid
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the co ntract
,
exce
p
t as noted in Section 4
(
C
)
below.
to the NJEDA a certified p ayroll record each pay period .
In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, p ayments of fringe benefits as listed in
the con tract have been or will be made to approp riate pro grams fo r the benefit
of su ch employees, except as noted in Section 4 (C) below.
N
.
J
.
S
.
A
.
34:11
-
4
.
1
et
seq
.
COST
PER
HOUR
IN
THE
FRINGE
BENEFIT
BOX
ON
PAGE
1
That any payrolls otherwise under this contract required to be submitted for the above
,p ()
