Fillable Printable Massachusetts Weekly Certified Payroll Report Form
Fillable Printable Massachusetts Weekly Certified Payroll Report Form
Massachusetts Weekly Certified Payroll Report Form
MASSACHUSETTS WEEKLY CERTIFI ED PAYROLL REPORT FORM
Company's Name: Address: Phone No.: Payroll No.:
Employer's Signature: Title: Contract No:
Tax Payer ID Number
Work W eek E nding:
Awarding Authority's Name: Public Works Project Name: Public Works Project Location: Mi n. W age Rate Sheet Number
General / Pri m e Contractor's Name: Subcontractor's Name:
"Employ er" Hourly Fringe Benefit Contributions
(B+C+D+E) (A x F)
Employee Name & Complete
A
ddress
Work
Classification:
Employee
is OSHA
10
certified
(?)
Appr.
Rate
(
%
)
Su. Mo. Tu. We. Th. Fr. Sa.
All Other
Hours
Hourly
Base
Wage
(
B
)
Health &
Welfare
Insuranc e
(
C
)
ERISA
Pension
Plan
(
D
)
Supp.
Unemp.
(
E
)
Total
Hourly
Prev . Wage
(
F
)
Total Gross
Wages
Check No.
(
H
)
Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards?
YES NO
No apprentices are identified above
Date Rec ei ved by Awarding Authority
Page ________of________ / /
NOTE: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding
authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the
commencement of a criminal action or the issuance of a civil citation.
For all apprentices performing work during the reporting period, attach a copy of the apprentice identification card issued
by the Massachusetts Department of Labor Standards / Division of Apprentice Standards.
Hours Worked
Project
Gross
Wages
Project
Hours
(A)
