Nyc Comptrollerbureau Of Labor Law Payroll Form - Nyc Parks
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1
2THE CITY OF NEW YORK
•
OFFICE OF THE COMPTROLLER
•
BUREAU OF LABOR LAW
PAYROLL REPORT
NAME OF PRIME CONTRACTOR
AGENCY
TO BE SUBMITTED WITH REQUISITION FOR PAYMENT
NAME OF CONTRACTOR/SUBCONTRACTOR
ADDRESS
PHONE #
PAYROLL #
TAX I.D. #
CONTRACT REGISTRATION #
JOB CODE
WEEK ENDING DATE
PROJECT NAME & LOCATION
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
DAY AND DATE
SUPPLEMENTAL BENEFITS
LIST TRADE & CHECK
NAME
CLASSIFICATION
T
BASE
ADDRESS
JOURNEYMAN
I
RATE
PAID TO
TOTAL
TOTAL
RATE OF
TOTAL
TOTAL TAX &
NET PAY
M
GROSS PAY
APPRENTICE
PER
(Local # if Union is
BENEFITS
HOURS
PAY PER
BASE
OTHER
LAST FOUR DIGITS OF
E
(NYS DOL REGISTERED)
HOUR
checked)
PAID
HOUR
PAY
DEDUCTIONS
SOCIAL SECURITY NUMBER
HELPER
HOURS WORKED EACH DAY
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
INSTRUCTIONS ON REVERSE SIDE
FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE
This certified payroll has been prepared in accordance with the instructions contained on the reverse side of this form. I certify that the above information represents wages and supplemental
benefits paid to all persons employed by my firm for construction work on the above project during the period shown. I understand that falsification of this statement is a punishable offense.
___________________________
_____________________________________
________________________________
____________________________ ,20______
SIGNATURE
NAME (Print)
TITLE
DATE
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