Fillable Printable Weekly Payroll Certification for Public Works Projects
Fillable Printable Weekly Payroll Certification for Public Works Projects
Weekly Payroll Certification for Public Works Projects
[New] In accordance with Section 31-53b(a) of the CG.S. each contractor shall provide a copy of the OSHA 10 Hour Construction Safety and Health Card for each employee, to be attached to the first
certificd payroll on the project.
In accordance with Connecticut General Statutes, 31-53
PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
Connecticut Department of Labor
Certified Payrolls with a statement of compliance
Wage and Workplace Standards Division
shall be submitted monthl}' to the contracting agency.
WEEKLY PAYROLL
200 Foil)' Brook 81vd.
Wethersfield, CT 06109CONTRACTOR NAME AND ADDRESS:
SUBCONTRACTOR NAME
& ADDRESSWORKER'S COMPENSATION INSURANCE CARRIER
landon Corporation. 15 Connecticut Avenue, Northford, CT 06472
XYZ Corporation
Travelers Insurance Company
2 Main Street
POLICY # #BAC8888928
PA YROLL NUMBER
Week-Ending
PROJECT NAME
& ADDRESS
Yantic, CT 06389
Date
DOT 105-296, Route 82
EFFECTIVE DATE: 1/1/09
1
9/26/09
EXPIRATION DATE: 12/31/09
PERSON/WORKER,
APPRMALE!
WORK DAY AND DATE
Tolal ST
BASE 1I0URL Y
TYPE OFGROSS PAYTOTAL DEDUCTIONSGROSS PAY FOR
ADDRESS and SECTION
RATEFEMALE
CLASSIFICATION
SM
T
WTIIFSHoursRATEFRINGEFOR ALL
FEDERAL
STATE THIS PREVAILING
CHECK # AND
%
AND
BENEFITS
WORK RATE JOB
NET PAY
RACE'
Trade License Type
20
21
2223
2425
26
TOTAL FRINGE
Per HourPERFORMED LIST
& Number - OSHA
Total
BENEFIT PLAN
I through 6
THIS WEEKFICA
WITH-WITH-
OTHER
10 Certification
Number
HOURS WORKED EACH DAY
Off Hou
CASH
(see back)
HOLDING
HOLDING
Robert Craft
S-TIME
I.
$ 5.80
M/C
Electrical Lineman
$ 30.75
#123
81 Maple Street
E-1 1234567
8
8
88
8
2
$
$1,582.80 P-xxxx
$1,582.80
Owner
40
Base Rate
3
$ 2.01
Willimantic, CT 06226 OSHA 123456
4. $
$ xxx.xx
O-TIME
$ 8.82
5.
$
Cash Fringe
6.
$
S-TIME
I. $
Ronald Jones
65%
MISElectrical
8
8
88
8
$ 19.99
2.
$
$1,464.80
G-xxx
#124
xx.xx
xxx.xx
xx.xx
$1,464.80
212 Elm Street
Apprentice
40
Norwich, CT 06360
Base Rate
3.
$
$xxx.xx
OSHA 234567
O-TIME
4.
$
$
16.63
5. $
Cash Fringe
6.
$
Franklin T. Smith
S-TIME
I.
$
MIH
Project Manager
8
$
#125
234 Washington Rd.
2. $
$1,500.00
xx.xx
xx.xx
xx.xx
M-xx.x
8
New london. CT
Base Rate
3.
$
06320
0- TIME
4. $
xxx.XX
SECTION B
$
5. $
Cash Fringe
6.
$
S-TIME
1. $
$
2. $
Base Rate
3.
$
O-TIME
4.
$
$
5. $
Cash Frinl.!e
6
$
7/13/2009
'IF REQUIRED
I
OF ;:L
WWS-CPI
'SEE REVERSE SIDE
PAGE NUMBER
OSHA 10 -ATIACH CARD TO 1ST CERTIFIED PAYROLL
*FRINGE BENEFITS EXPLANATION (P):
Bona fide benefits paid to approved plans, funds or programs, except those required by Federal or State
Law (unemployment tax, worker's compensation, income taxes, etc.).
Please specify the type of benefits provided:
1) Medical or hospital care
Blue Cross 4) Disability _
2) Pension or retirement 5) Vacation, holiday _
3) Life Insurance
Utopia 6) Other (please specify) _
CERTIFIED STATEMENT OF COMPLIANCE
For the week ending date of 9/26/09
-----------'
I, Robert Craft
of XYZ Corporation
, (hereafter known as
Employer) in my capacity as
Owner (title) do hereby certify and state:
Section A:
I. All persons employed on said project have been paid the full weekly wages earned by them during
the week in accordance with Connecticut General Statutes, section 31-53, as amended. Further, I
hereby certify and state the following:
a) The records submitted are true and accurate;
b) The rate of wages paid to each mechanic, laborer or workman and the amount of payment or
contributions paid or payable on behalf of each such employee to any e'mployee welfare fund, as
defined in Connecticut General Statutes, section 31-53 (h), are not less than the prevailing rate
of wages and the amount of payment or contributions paid or payable on behalf of each such
employee to any employee'welfare fund, as determined by the Labor Commissioner pursuant to
subsection Connecticut General Statutes, section 31-53 (d), and said wages and benefits are not
less than those which may also be required by contract;
c) The Employer has complied with all of the provisions in Connecticut General Statutes,
section 31-53 (and Section 31-54 if applicable for state highway construction);
d) Each such employee of the Employer is covered by a worker's compensation insurance
policy for the duration of his employment which proof of coverage has been provided to the
contracting agency;
e) The Employer does not receive kickbacks, which means any money, fee, commission, credit,
gift, gratuity, thing of value, or compensation of any kind which is provided directly or
indirectly, to any prime contractor, prime contractor employee, subcontractor, or subcontractor
employee for the purpose of improperly obtaining or rewarding favorable treatment in
connection with a prime contract or in connection with a prime contractor in connection with a
subcontractor relating to a prime contractor; and
f) The Employer is aware that filing a certified payroll which he knows to be false is a class D
felony for which the employer may be fined up to five thousand dollars, imprisoned for up to
five years or both.
2. OSHA-The employer shall affix a copy of the construction safety course, program or
training completion document to the certified payroll required to be submitted to the contracting
agency for this project on which such employee's name first appears.
~~~
(Signature) ,
ow~
(Title)
/o/~-)t/ Cj
Submitte6 on (.Date)
Section B: Applies to CONNDOT Projects ONLY
That pursuant to CONNDOT contract requirements for reporting purposes only, all employees
listed under Section B who performed work on this project are not covered under the prevailing
wageRquirements defined in Connecticut General Statutes Section 31-53.
ou/I.../e;"-
(Title)
Note: CTDOL will assume all hours worked were performed under Section A unless clearly
delineated as Section B WWS-CP I as such. Should an employee perform work under both
Section A and Section B, the hours worked and wages paid must be segregated for reporting
purposes.
***THIS IS A PUBLIC DOCUMENT***
***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***
