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Certified Payroll Report Template

The document is a Certified Payroll Report used by employers to report employee wages and hours worked on a specific project. It includes details such as employee names, hours worked, pay rates, and fringe benefits, along with a certification statement ensuring compliance with prevailing wage laws. The report must be signed by an authorized individual, affirming the accuracy of the information provided.

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29 views1 page

Certified Payroll Report Template

The document is a Certified Payroll Report used by employers to report employee wages and hours worked on a specific project. It includes details such as employee names, hours worked, pay rates, and fringe benefits, along with a certification statement ensuring compliance with prevailing wage laws. The report must be signed by an authorized individual, affirming the accuracy of the information provided.

Uploaded by

4vk4v5rpyv
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CERTIFIED PAYROLL REPORT

Employer Name & Address Name of General / Prime Contractor Project Name & Location Contracting Public Authority

Check if subcontractor Week Ending Payroll # Project Number

Page_______Of________

2. 4. 5. 6. 7. Fringes: 8. Total 9. Total 10. 11. 12.


1. Employee Name, Address Work 3. Hours Worked - Day & Date Project Base Project Cash Hours Gross Taxes Other NET
and Social Security Number Class Total Hrs. Rate Gross Approved Plans All Jobs All Jobs Withheld Deducts Paid
Cash & Approved Plans

H&W Pens Vac App Other

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

Date_________________My signature on this form signifies that I pay, or supervise the payment of the employees shown above. I am certifying: 1) That during the pay period reported on this
form, all hours worked on this project have been paid at the appropriate prevailing wage rate for the class of work done. 2) That the fringe benefits have been paid as indicated above. 3) That no
rebates or deductions have been or will be made, directly or indirectly from the total wages earned, other than permissable deductions as defined in the Ohio Revised Code Chapter 4115.
4) That apprentices are registered with the U.S. Department of Labor, Bureau of Apprenticeship and Training. The willful falsification of any of the above statements may subject the contractor or
subcontractor to civil or criminal prosecution.

Name and Title __________________________ Signature __________________________

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