Fillable Printable Weekly Payroll Certification for Public Works Projects - Pennsylvania
Fillable Printable Weekly Payroll Certification for Public Works Projects - Pennsylvania
Weekly Payroll Certification for Public Works Projects - Pennsylvania
SUBCONTRACTOR
WEEKLY PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
210 Lakeview Road
Sometown, PA 99999
PROJECT AND
LOCATION
Sample project for demonstration only
PROJECT # 54-67-89PROJECT SERIAL # 7200A
PAYROLL NUMBER
1
WEEK ENDING DATE
06/30/2007
EMPLOYEE NAME
APPR
RATE
(%)
WORK
CLASSIFICATION
S-
TIME
O-
TIME
DAY AND DATE
HOURS WORKED EACH DAY
BASE
HOURLY
RATE
GROSS PAY
FOR
PREVAILING
RATE JOB(S)
TOTAL
DEDUCTIONS
TOTAL FRINGE
BENEFITS
(C=Cash)
(FB=Contributions)*
CHECK #
(Please check one)
CONTRACTOR
ADDRESS ADDRESS
BUREAU OF LABOR LAW COMPLIANCE
PREVAILING WAGE DIVISION
7TH & FORSTER STREETS
HARRISBURG, PA 17120
1-800-932-0665
ALL INFORMATION MUST BE COMPLETED
06/24 06/25 06/26 06/27 06/28 06/29 06/30
Su Mo Tu We Th Fr Sa
L
Y
INDUSTR
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF
&
ABOR
SubcontractorContractor or
ABC Contractors
18.00
24
0
Jane Doe
71 Pineapple Lane
Sometown, PA 99999
Pipe Fitter
FB:
C:
0 0 0 0 0 0 0
0 8 8 8 0 0 0
432.00178.54
8100
0.00
10.50
20.00
24
0
John Doe
P.O. Box 999
Sometown, PA 99999
Sheetmetal Worker
FB:
C:
0 0 0 0 0 0 0
0 8 8 8 0 0 0
480.00207.19
8109
0.00
10.50
22.00
24
0
John Q. Public
2300 Arena Avenue
Sometown, PA 99999
Truck Driver
FB:
C:
0 0 0 0 0 0 0
0 8 8 8 0 0 0
528.00169.68
8118
0.00
10.50
14.00
24
0
John Smith
36 Mimosa Lane
Sometown, PA 99999
Laborer
FB:
C:
0 0 0 0 0 0 0
0 8 8 8 0 0 0
336.00119.90
8125
0.00
10.50
FB:
C:
FB:
C:
LLC-25 REV 10-03 (Page 1)
1 PAGE NUMBER 1 OF* SEE REVERSE SIDE
Taken, sworn and subscribed before me this ________ Day
of __________________________ A.D., ______________
THE NOTARIZATION MUST BE COMPLETED ON FIRST AND LAST SUBMISSIONS ONLY. ALL OTHER
*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)
2)
3)
4)
5)
6)
Medical or hospital care
Pension or retirement
Life Insurance
Disability
Vacation, holiday
Other (please specify)
CERTIFIED STATEMENT OF COMPLIANCE
1. The undersigned, having executed a contract with
This is a sample project for demonstration purposes only
Awarding Agency
(AWARDING AGENCY, CONTRACTOR OR SUBCONTRACTOR)
(a) The prevailing wage requirements and the predetermined rates are included in the aforesaid contract.
for the construction of the above-identified project, acknowledges that:
(b) Correction of any infractions of the aforesaid conditions is the contractor's or subcontractor's responsibility.
(c) It is the contractor's responsibilty 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: a single proprietorship a corporation organized in the state of Pennsylvania
a partnership other organization (describe)
(c) The name, title and address of the owner, partners or officers of the contractor/subcontractor are:
NAME TITLE ADDRESS
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.
(DATE) (SIGNATURE)
(TITLE)
President
SEAL
Pension or retirement benefits
Life Insurnace benefits
Disability benefits
Vacation, holiday benefits
Other benefits
Cory Smith/Partner
Tom Jones/Partner
President
Vice President/Project Manager
210 Lakeview Road, Sometown, PA 99999
210 Lakeview Road, Sometown, PA 99999
INFORMATION MUST BE COMPLETED WEEKLY.
LLC-25 REV 10-03 (Page 2)
