- Certified Payroll - Michigan Department of Transportation
- Certified Payroll Form - Minnesota Department of Labor and Industry
- Certification of Payroll by Officer - New York
- Statement of Compliance - California
- Certified Payroll Report - Ohio
- Weekly Payroll Records Report and Statement of Compliance - Massachusetts
Fillable Printable Payroll Certification - New Jersey
Fillable Printable Payroll Certification - New Jersey
Payroll Certification - New Jersey
PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
(for Contractor and Sub-Contractor’s Use for Weekly and Final Certification)
(N.J.A.C. 12:60-2.1 and 6.1)
NJ Department of Labor & Workforce Development
Division of Wage and Hour Compliance
Public Contracts Section
P.O. Box 389
Trenton, New Jersey 08625-0389
Submit to Public Body or Lessor
NAME OF CONTRACTOR OR SUBCONTRACTOR ADDRESS DATE WAGES DUE AND PAID
PAYROLL NO. WEEK ENDING OR FINAL CERTIFICATION
PROJECT NAME AND LOCATION PROJECT OR E.D.A. OR U.D.C. NO.
3. DAY AND DATE
6.
GROSS
AMOUNT
EARNED
7.
DEDUCTIONS
1.
NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE
2.
WORK
CLASSIFICATION
OT. OR ST.
HOURS WORKED EACH DAY
4.
TOTAL
HOURS
5.
RATE
OF PAY
THIS
PROJECT
THIS
WEEK
FICA
WITH-
HOLDING
TAX
TOTAL
DEDUC-
TIONS
8.
NET
WAGES
PAID FOR
WEEK
9.
Total
Fringe
Benefit
Cost/Hr.
O
S
O
S
O
S
O
S
O
S
O
S
O
S
Date
I,
(Name of signatory party) (Title)
do hereby state and certify:
(1) That I pay or supervise the payment of the persons employed by
on the ;
(Contractor or Subcontractor) (Building or Work)
that during the payroll period commencing on the
day of , 20 , and ending the
day of , 20 , 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
from the full
(Contractor or Subcontractor)
weekly wages earned by any person and that no deductions have been made either directly or indirectly from the
full wages earned by any person, other than permissible deductions as defined in the New Jersey Prevailing 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.
(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct
and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage
rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for
each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in good standing, in an
apprenticeship program approved or certified by the Division of Vocational Education in the New Jersey
Department of Education or by the Bureau of Apprenticeship Training in the United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above
referenced payroll, payments of fringe benefits as listed in the contract have been or will be
made to appropriate programs for the benefit of such employees, except as noted in Section
4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed in the above referenced 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 contract, except as noted in Section 4(c)
below.
(c) FRINGE BENEFITS
EXCEPTIONS (CRAFT)
REMARKS
PLEASE SPECIFY THE TYPE OF BENEFIT PROVIDED AND NOTE THE TOTAL COST PER
HOUR IN BLOCK 9 ON THE REVERSE SIDE*
1) Medical or hospital coverage
2) Dental coverage
3) Pension or Retirement
4) Vacation, Holidays
5) Sick days
6) Life Insurance
7) Other (Explain)
* TO CALCULATE THE COST PER HOUR, DIVIDE 2,000 HOURS INTO THE BENEFIT
COST PER YEAR PER EMPLOYEE.
(5) N.J.S.A. 12:60-2.1 and 6.1 - The Public Works employers shall submit to the public body or lessor a
certified payroll record each pay period within 10 days of the payment of wages.
Contractor Registration Number
NAME AND TITLE
THE FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR
OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. N.J.S.A. 34:11-56.25 ET SEQ. AND
N.J.A.C. 12:60 ET SEQ. AND N.J.S.A. 34:11-4.1 ET SEQ.
