Fillable Printable Weekly Payroll - New York

Weekly Payroll - New York

WEEKLY PAYROLL

Department of Labor

Bureau of Public Work

For Contractor's Optional Use. The use of this form meets payroll notification requirements; as stated

on the Payroll Records Notification.

NAME OF CONTRACTOR

SUBCONTRACTOR

ADDRESS

FEIN

FOR WEEK ENDING

PROJECT OR CONTRACTOR NO.

PROJECT AND LOCATION

(a)

4) DAY AND DATE

(9)

(1)

(2)

(3)

(6)

(5)

(7)

NET WAGES

DEDUCTIONS

NAME, ADDRESS, AND

NO. OF

GROSS

RATE

PAID

WITH-

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

WORK

AMOUNT

TOTAL

WITH-

HOLDING

Tax

FOR WEEK

TOTAL

HOLDINGS

CLASSIFICATION

EARNED

PAY

HOURS

HOURS WORKED EACH DAY

PW -12 (1-09)

OF EMPLOYEE

FICA OTHER DEDUCTIONS

THIS CERTIFICATION MUST BE COMPLETED ON EACH WEEKLY PAYROLL FORM USED BY THE CONTRACTOR OR SUBCONTRACTOR

Date

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

(Name of signatory party)

(Title)

- Each laborer, worker, 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.

do hereby state:

(1) That I pay or supervise the payment of the persons employed by

(Contractor or Subcontractor)

, that during the payroll period commencing on the

day of

, 20 , and ending the

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 indirectly to or on behalf of said

EXPLANATION

EXCEPTION (CRAFT)

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 full wages earned by any person, other than permissible deductions as

defined in Articles 8 and 9 and described below:

(2) That any payrolls submitted for the above period are correct and complete; that the

wage rates for laborers, workers, or mechanics contained therein are not less than the

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

the classifications set forth therein for each laborer, worker or mechanic conform with the work

he/she performed.

REMARKS:

(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 States Department of Labor, or if no such recognized

agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United

States Department 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, worker 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).

SIGNATURE

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

TO CIVIL OR CRIMINAL PROSECUTION. SEE ARTICLES 8 AND 9.