Certified Payroll Report

CERTIFIED PAYROLL REPORT

Name of General / Prime Contractor

Employer Name & Address

Project Name & Location

Contracting Public Authority

Check if subcontractor

Week Ending

Payroll #

Project Number

Page_______Of________

7. Fringes:

2.

5.

11.

12.

4.

6.

8. Total

9. Total

10.

Cash

Work

Base

Other

NET

1. Employee Name, Address

3. Hours Worked - Day & Date

Project

Project

Hours

Gross

Taxes

Approved Plans

Class

Rate

Deducts

Paid

and Social Security Number

Total Hrs.

Gross

All Jobs

All Jobs

Withheld

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 __________________________