Public Works Payroll Reporting Form

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California
Department
PUBLIC WORKS PAYROLL REPORTING FORM
of Industrial
Page
of
Relations
NAME OF CONTRACTOR
CONTRACTORS LICENSE #
ADDRESS
OR SUB CONTRACTOR
SPECIALTY LICENSE #
PAYROLL NO.
FOR WEEK ENDING
SELF-INSURED CERTIFICATE #
PROJECT OR CONTRACT NO.
WORKERS' COMPENSATION POLICY #
PROJECT AND LOCATION
(1)
(2)
(3)
(5)
(6)
(4)
Day
M
T
W
TH
F
S
S
(7)
NAME, ADDRESS AND
HOURLY
WORK
TOTAL
Date
SOCIAL SECURITY NUMBER
OF
RATE
GROSS AMOUNT
CLASSIFICATION
HOURS
NET WGS
EMPLOYEE
OF PAY
EARNED
PAID FOR
CHECK
Hours Worked Each Day
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
WEEK
NO.
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
PROJECT PROJECTS
TAX
(SOC SEC)
TAX
HOL
& WELF
S
TRANING
FUND
DUES
TRV/
SAVINGS
OTHER*
TOTAL DED-
O
ADMIN
SUBS
UCTIONS
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
PROJECT PROJECTS
TAX
(SOC SEC)
TAX
HOL
& WELF
S
TRANING
FUND
DUES
TRV/
SAVINGS
OTHER*
TOTAL DED-
O
ADMIN
SUBS
UCTIONS
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
PROJECT PROJECTS
TAX
(SOC SEC)
TAX
HOL
& WELF
S
TRANING
FUND
DUES
TRV/
SAVINGS
OTHER*
TOTAL DED-
O
ADMIN
SUBS
UCTIONS
THIS
ALL
FED
FICA
STATE
SDI
VAC/
HEALTH
PENSION
PROJECT PROJECTS
TAX
(SOC SEC)
TAX
HOL
& WELF
S
TRANING
FUND
DUES
TRV/
SAVINGS
OTHER*
TOTAL DED-
O
ADMIN
SUBS
UCTIONS
*OTHER - Any other deductions, contributions and/or payment whether or not included or required by prevailing
CERTIFICATION must be completed
Form A 1-131 (New 2-80
S = Straignt Time
(form has been minimized to fit page)
O = Overtime
wage determinations must be separately listed. Use extra sheet if necessary
SDI = State Disability Insurance
I,
, the undersigned, am
with the authority to act for and on behalf of
,
(Name - Print)
(position with business)
(name of business and/or contractor)
certify under penalty of perjury that the records or copies thereof submitted and consisting of
are the originals or true, full and correct copies of the originals which depict the payroll
(description, no. of pages)
record(s) of the actual disbursements by way of cash, check,or whatever form to the individual or individuals named.
Date:
Signature:
A public entity may require a more strict and/or more extensive form of certification.

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