Payroll Dates Form

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Payroll Dates Form
INSTRUCTIONS TO THE CONTRACTOR: Please read the following and provide the required
information noted on this form. This document must be submitted to the Prevailing Wage
Coordinator for the public authority on or before your company starts any work under a contract for a
public improvement. This requirement is also applicable to your subcontractors. Please make a
copy of this document available to them. The prevailing wage laws state that contractors are
responsible for the actions of their subcontractors.
_______________________________ will begin performance under contract on the ____________
Name of Contractor
_______________________________________________ project on _________________ and
Name of Project and Location
Start Date
will conclude work on said project on ______________________.
Ending Date – if known
In accordance with section 4115.071 (C) of the Ohio Revised Code regarding listing of payroll
dates, I hereby submit the following schedule of dates that my company is required to pay wages to
its workers while on this project. (NOTE: If the life of the project is expected to be over three (3)
months in length, provide only the days of the week your pay period starts and ends, plus the day
you pay your workers.):
_________________________
_________________________
________________________
_________________________
_________________________
________________________
_________________________
_________________________
________________________
_________________________
_________________________
________________________
Day Pay Period Starts:
_____________________
Day Pay Period Ends:
_____________________
Day Workers are Paid: ____________________
I acknowledge that I am required by section 4115.071 (C) of the Ohio Revised Code to submit a
copy of my company’s certified payroll records for this project to the Prevailing Wage Coordinator of
the public authority within two weeks of the initial pay date listed above. I further acknowledge that I
am responsible to collect and submit my subcontractors’ prevailing wage documents, including their
certified payroll records in accordance with the law.
______________________________________
______________________________________
Contractor’s Signature and Title
Company Name
______________________________________
______________________________________
Date
Address
______________________________________
*Prime contractor and all subcontractors submit with first certified payroll report.

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