Fillable Printable Labor Certified Transcript of Payroll - Illinois

Labor Certified Transcript of Payroll - Illinois

State of Illinois

Illinois Department of Labor

Certified Transcript of Payroll

IL452CM01

Page 1 of 1

Please Note: The submission of falsified payroll records is a criminal offense.

IDOL Case File Number:

Payroll Date:

Company Name:

Contact Person:

(Address)

(City)

(State) (zipcode)

Telephone Number:

Contractor and/or Subcontractor

Contract Number:

Project Number:

Project:

Contract Information

Project Location:

Public Body Name:

Contact Person:

(Address)

(City)

(State) (zipcode)

Telephone Number:

Public Body Information

Report Hours for Each Day, Including Overtime Hours, List Hourly Prevailing Wage Rate and Hourly Fringe Benefits Allotments.

Employee Name, Address

SSN & Telephone Number

Labor

Classification

* Hours worked each day

SUN MON TUE WED THR FRI SAT

Total Hrs Each

PW and Reg.

Total OT Hourly Wage

OT Wage

Hours Rate

Rate

Per Pay Period

Gross Net

Hourly Fringe Benefit

Pension

Health & Welfare Vac. Training

(SSAN)

(Street)

(City, State Zip)

(Telephone #)

(Name)

INSTRUCTIONS

Fringe benefits (health insurance, pension, vacation, and training) must be paid, if it is required for the work classification, regardless of your union

or nonunion status. We give you credit for health insurance paid (if any) and ERISA approved pension plan (if any) and training if your employees are in a BAT

approved program. If the fringe benefit rate is paid into a fund, please note by placing the letter “F” behind the fringe benefit rate; if the fringe benefit rate is included

on an employee's payroll check, please note by placing the letter “E” behind the fringe benefit rate. On the back of this form please list all subcontractors,

independent contractors and owner operator's your company used on this project. If you wish information regarding coverage of the Act, please visit our web site at