- Certified Payroll Form - Minnesota Department of Labor and Industry
- Statement of Compliance - California
- Certified Payroll Report - Ohio
- Certification of Payroll by Officer - New York
- Weekly Payroll Records Report and Statement of Compliance - Massachusetts
- Certified Payroll - Michigan Department of Transportation
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]InaccordancewithSection31-53b(a)oftheCG.S.eachcontractorshallprovideacopyoftheOSHA10HourConstructionSafetyandHealthCardforeachemployee,tobeattachedtothefirst
certificdpayrollontheproject.
InaccordancewithConnecticutGeneralStatutes,31-53
PAYROLLCERTIFICATIONFORPUBLICWORKSPROJECTS
ConnecticutDepartmentofLabor
CertifiedPayrollswithastatementofcompliance
WageandWorkplaceStandardsDivision
shallbesubmittedmonthl}'tothecontractingagency.
WEEKLYPAYROLL
200Foil)'Brook81vd.
Wethersfield,CT06109CONTRACTORNAMEANDADDRESS:
SUBCONTRACTORNAME
&ADDRESSWORKER'SCOMPENSATIONINSURANCECARRIER
landonCorporation.15ConnecticutAvenue,Northford,CT06472
XYZCorporation
TravelersInsuranceCompany
2MainStreet
POLICY##BAC8888928
PAYROLLNUMBER
Week-Ending
PROJECTNAME
&ADDRESS
Yantic,CT06389
Date
DOT105-296,Route82
EFFECTIVEDATE:1/1/09
1
9/26/09
EXPIRATIONDATE:12/31/09
PERSON/WORKER,
APPRMALE!
WORKDAYANDDATE
TolalST
BASE1I0URLY
TYPEOFGROSSPAYTOTALDEDUCTIONSGROSSPAYFOR
ADDRESSandSECTION
RATEFEMALE
CLASSIFICATION
SM
T
WTIIFSHoursRATEFRINGEFORALL
FEDERAL
STATETHISPREVAILING
CHECK#AND
%
AND
BENEFITS
WORKRATEJOB
NETPAY
RACE'
TradeLicenseType
20
21
2223
2425
26
TOTALFRINGE
PerHourPERFORMEDLIST
&Number-OSHA
Total
BENEFITPLAN
Ithrough6
THISWEEKFICA
WITH-WITH-
OTHER
10Certification
Number
HOURSWORKEDEACHDAY
OffHou
CASH
(seeback)
HOLDING
HOLDING
RobertCraft
S-TIME
I.
$5.80
M/C
ElectricalLineman
$30.75
#123
81MapleStreet
E-11234567
8
8
88
8
2
$
$1,582.80P-xxxx
$1,582.80
Owner
40
BaseRate
3
$2.01
Willimantic,CT06226OSHA123456
4.$
$xxx.xx
O-TIME
$8.82
5.
$
CashFringe
6.
$
S-TIME
I.$
RonaldJones
65%
MISElectrical
8
8
88
8
$19.99
2.
$
$1,464.80
G-xxx
#124
xx.xx
xxx.xx
xx.xx
$1,464.80
212ElmStreet
Apprentice
40
Norwich,CT06360
BaseRate
3.
$
$xxx.xx
OSHA234567
O-TIME
4.
$
$
16.63
5.$
CashFringe
6.
$
FranklinT.Smith
S-TIME
I.
$
MIH
ProjectManager
8
$
#125
234WashingtonRd.
2.$
$1,500.00
xx.xx
xx.xx
xx.xx
M-xx.x
8
Newlondon.CT
BaseRate
3.
$
06320
0-TIME
4.$
xxx.XX
SECTIONB
$
5.$
CashFringe
6.
$
S-TIME
1.$
$
2.$
BaseRate
3.
$
O-TIME
4.
$
$
5.$
CashFrinl.!e
6
$
7/13/2009
'IFREQUIRED
I
OF;:L
WWS-CPI
'SEEREVERSESIDE
PAGENUMBER
OSHA10-ATIACHCARDTO1STCERTIFIEDPAYROLL
*FRINGEBENEFITSEXPLANATION(P):
Bonafidebenefitspaidtoapprovedplans,fundsorprograms,exceptthoserequiredbyFederalorState
Law(unemploymenttax,worker'scompensation,incometaxes,etc.).
Pleasespecifythetypeofbenefitsprovided:
1)Medicalorhospitalcare
BlueCross4)Disability_
2)Pensionorretirement5)Vacation,holiday_
3)LifeInsurance
Utopia6)Other(pleasespecify)_
CERTIFIEDSTATEMENTOFCOMPLIANCE
Fortheweekendingdateof9/26/09
-----------'
I,RobertCraft
ofXYZCorporation
,(hereafterknownas
Employer)inmycapacityas
Owner(title)doherebycertifyandstate:
SectionA:
I.Allpersonsemployedonsaidprojecthavebeenpaidthefullweeklywagesearnedbythemduring
theweekinaccordancewithConnecticutGeneralStatutes,section31-53,asamended.Further,I
herebycertifyandstatethefollowing:
a)Therecordssubmittedaretrueandaccurate;
b)Therateofwagespaidtoeachmechanic,laborerorworkmanandtheamountofpaymentor
contributionspaidorpayableonbehalfofeachsuchemployeetoanye'mployeewelfarefund,as
definedinConnecticutGeneralStatutes,section31-53(h),arenotlessthantheprevailingrate
ofwagesandtheamountofpaymentorcontributionspaidorpayableonbehalfofeachsuch
employeetoanyemployee'welfarefund,asdeterminedbytheLaborCommissionerpursuantto
subsectionConnecticutGeneralStatutes,section31-53(d),andsaidwagesandbenefitsarenot
lessthanthosewhichmayalsoberequiredbycontract;
c)TheEmployerhascompliedwithalloftheprovisionsinConnecticutGeneralStatutes,
section31-53(andSection31-54ifapplicableforstatehighwayconstruction);
d)EachsuchemployeeoftheEmployeriscoveredbyaworker'scompensationinsurance
policyforthedurationofhisemploymentwhichproofofcoveragehasbeenprovidedtothe
contractingagency;
e)TheEmployerdoesnotreceivekickbacks,whichmeansanymoney,fee,commission,credit,
gift,gratuity,thingofvalue,orcompensationofanykindwhichisprovideddirectlyor
indirectly,toanyprimecontractor,primecontractoremployee,subcontractor,orsubcontractor
employeeforthepurposeofimproperlyobtainingorrewardingfavorabletreatmentin
connectionwithaprimecontractorinconnectionwithaprimecontractorinconnectionwitha
subcontractorrelatingtoaprimecontractor;and
f)TheEmployerisawarethatfilingacertifiedpayrollwhichheknowstobefalseisaclassD
felonyforwhichtheemployermaybefineduptofivethousanddollars,imprisonedforupto
fiveyearsorboth.
2.OSHA-Theemployershallaffixacopyoftheconstructionsafetycourse,programor
trainingcompletiondocumenttothecertifiedpayrollrequiredtobesubmittedtothecontracting
agencyforthisprojectonwhichsuchemployee'snamefirstappears.
~~~
(Signature),
ow~
(Title)
/o/~-)t/Cj
Submitte6on(.Date)
SectionB:AppliestoCONNDOTProjectsONLY
ThatpursuanttoCONNDOTcontractrequirementsforreportingpurposesonly,allemployees
listedunderSectionBwhoperformedworkonthisprojectarenotcoveredundertheprevailing
wageRquirementsdefinedinConnecticutGeneralStatutesSection31-53.
ou/I.../e;"-
(Title)
Note:CTDOLwillassumeallhoursworkedwereperformedunderSectionAunlessclearly
delineatedasSectionBWWS-CPIassuch.Shouldanemployeeperformworkunderboth
SectionAandSectionB,thehoursworkedandwagespaidmustbesegregatedforreporting
purposes.
***THISISAPUBLICDOCUMENT***
***DONOTINCLUDESOCIALSECURITYNUMBERS***
