Fillable Printable Payroll U.S. Department of Labor

Payroll U.S. Department of Labor

U.S. Department of Labor

PAYROLL

Employment Standards A dm i nist ration

(For Contractor's Optional Use; See Instructions, Form WH-347 Inst.)

Wage and Hour Division

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.

NAME OF CONTRACTOR OR SUBCONTRACTOR

ADDRESS

OMB No.: 1215-0149

Expires: 03/31/2006

PAYROLL NO. FOR WEEK ENDING

PROJECT AND LOCATION

PROJECT OR CONTRACT NO.

(1) (2) (3) (4) DAY AND DATE (5) (6) (7) (9)

(8)

DEDUCTIONS

NAME, ADDRESS, AND

SOCIAL SECURITY NUMBER

OF EMPLOYEE

NO. OF

W ITHHOLDiNG

EXEMPTIONS

WORK

CLASSIFICATION

OT. OR ST.

HOURS WORKED EACH DAY

TOTAL

HOURS

RATE

OF PAY

GROSS

AMOUNT

EARNED FICA

WITH-

HOLDING

TAX OTHER

TOTAL

DEDUCTIONS

NET

WAGES

PAID

FOR WEEK

We estimate that it will take an average of 56 minutes to complete this collection of information, including time for reviewing instructions searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection of

information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, ESA, U. S. Department of Labor, Room S3502, 200 Constitution

Avenue, N. W., Washington, D. C. 20210.

FORM WH-347, Revised Nov. 1998 - FORMERLY SOL 184 -

PURCHASE THIS FORM DIRECTLY FROM THE SUPT. OF DOCUMENTS

Date

(Name of Signatory Party) (Title)

do hereby state:

(1) That I pay or superv is e t he payment of t he pers ons em ployed by

on the

(Contractor or Subcontractor)

; that during the payroll period commencing on the

(Building or Work)

day of , , and ending the day of , ,

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 indirect ly to or on behalf of s aid

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 f ull wages earned by any person, other than permiss ible deduc t ions as defined in Regulations, Part

3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 St at. 948,

63 Start. 108, 72 St at . 967; 76 St at . 357; 40 U.S. C. 276c ), and des c ribed below:

(2) That any payrolls otherwise under this contract required to be submitted for the above period are

correct and complete; that t he wage rates for laborers or mec hanics contained t herein are not less than t he

applicable wage rates contained in any wage determination Incorporated into the contract; that the

classif ic at ions s et f ort h t herein f or eac h laborer or m ec hanic c onf orm with the work he performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide

apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of

Apprenticeship and Training, United St at es Departm ent of Labor, of if no s uc h rec ognized agency exists in a

State, are regis t ered with the Bureau of Apprentices hip and Training, United St at es Departm ent 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.

REMARKS:

EXCEPTION (CRAFT)

EXPLANATION

NAME AND TITLE SIGNATURE

THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR

SUBCONTRACTOR T O CIVIL OR CRI MINAL PROSECUTIO N. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE

31 OF THE UNITED STATES CODE.

* U.S. G.P.O.:1997 519.861