Fillable Printable Weekly Payroll Certification for Public Works - Pennsylvania
Fillable Printable Weekly Payroll Certification for Public Works - Pennsylvania
Weekly Payroll Certification for Public Works - Pennsylvania
LLC-25 REV 10-03 (Page 1)
WEEKLY PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
Contractor or Subcontractor (Please check one) ALL INFORMATION MUST BE COMPLETED
BUREAU OF LABOR LAW COMPLIANCE
PREV AILING W AGE DIVISION
7TH & FORSTER STREETS
HARRISBURG, PA 17120
1-800-932-0665
CONTRACTOR SUBCONTRACTOR
ADDRESS ADDRESS
PAYROLL NUMBER WEEK ENDING DATE PROJECT AND LOCATION
PROJECT SERIAL # PROJECT #
EMPLOYEE NAME
APPR.
RATE
(%)
WORK
CLASSIFICATION
DAY AND DATE
HOURS WORKED EACH DAY
S-
TIME
0-
TIME
BASE
HOURLY
RATE
T OTAL FRINGE
BENEFITS
(C=Cash)
(FB=Contributions)*
TOT AL
DEDUCTIONS
GROSS PAY
FOR
PREVAILING
RATE JOB(S)
CHECK #
C:
FB:
C:
FB:
C:
FB:
C:
FB:
C:
FB:
*SEE REVERSE SIDE
PAGE NUMBER ___________ OF ____________
THE NOTARIZATION MUST BE COMPLETED ON FIRST AND LAST SUBMISSIONS ONLY. ALL OTHER
INFORMATION MUST BE COMPLETED WEEKLY.
*FRINGE BENEFITS EXPLANATION (FB): Bona fide benefits contribution, except those required by Federal or State
Law (unemployment tax, workers’ compensation, income taxes, etc.)
Please specify the type of benefits provided and contributions per hour:
1) Medical or hospital care__________________________________________________________________________
2) Pension or retirement ____________________________________________________________________________
3) Life insurance _________________________________________________________________________________
4) Disability _____________________________________________________________________________________
5) Vacation, holiday _______________________________________________________________________________
6) Other (please specify) ___________________________________________________________________________
CERTIFIED STATEMENT OF COMPLIANCE
1. The undersigned, having executed a contract with _____________________________________________________
______________________________ for the construction of the above-identified project, acknowledges that:
(a) The prevailing wage requirements and the predetermined rates are included in the aforesaid contract.
(b) Correction of any infractions of the aforesaid conditions is the contractor’s or subcontractor’s responsibility.
(c) It is the contractor’s responsibility to include the Prevailing Wage requirements and the predetermined rates in
any subcontract or lower tier subcontract for this project.
2. The undersigned certifies that:
(a) Neither he nor his firm, nor any firm, corporation or partnership in which he or his firm has an interest is debarred
by the Secretary of Labor and Industry pursuant to Section 11(e) of the PA Prevailing Wage Act, Act of August
15, 1961, P.L. 987
as amended, 43 P.S.§ 165-11(e).
(b) No part of this contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm,
corporation or partnership in which such subcontractor has an interest is debarred pursuant to the aforementioned
statute.
3. The undersigned certifies that:
(a) the legal name and the business address of the contractor or subcontractor are: _________________________
_________________________________________________________________________________________
(b) The undersigned is:
( c ) The name, title and address of the owner, partners or officers of the contractor/subcontractor are:
The willful falsification of any of the above statements may subject the contractor to civil or criminal prosecution, provided in
the PA Prevailing Wage Act of August 15, 1961, P.L. 987,
as amended, August 9, 1963, 43 P.S. § 165.1 through 165.17.
(AWARDING AGENCY, CONTRACTOR OR SUBCONTRACTOR)
a single proprietorship a corporation organized in the state of ______________
a partnership other organization (describe) ____________________________
NAME TITLE ADDRESS
(DATE)
SEAL
(SIGNATURE)
(TITLE)
Taken, sworn and subscribed before me this _________ Day
of ___________________________________ A.D., ___________
LLC-25 REV 10-03 (Page 2)
