Instructions To Contractors For Certified Payroll Submittal Affidavit (Page 2 of 2) in pdf

Certification of

Certified Payroll Records (CPRs)

Submittal to Labor Commissioner

I am the _________________________________For___________________________________

(Job Title) (Contractor’s Business Name)

In connection with ______________________________________________________________

(Job Description/Purchase Order #)

This Certification is submitted to the Coast Community College District concurrently with the Contractor’s

submittal of an Application for Progress Payment and/or Invoice.

Invoice/Application for Progress Payment # _______________________________

1. The Pay Application/Invoice requests the Coast Community College District’s Disbursement of a Progress

Payment covering work performed during the

Time Period _________________ through _________________.

(Date) (Date)

2. The Contractor has submitted Certified Payroll Records (CPRs) to the Labor Commissioner for all

employees of the Contractor engaged in performance of work subject to prevailing wage rate

requirements for the period of time covered by the Pay Application/Invoice.

3. All Subcontractors who are entitled to any portion of payment to be disbursed pursuant to the Pay

Application have submitted the CPRs to the Labor Commissioner for all of their employees performing

work subject to the prevailing wage rate requirements for the period of time covered by the Pay

Application.

4. I have reviewed the Contractors’ CPRs submitted to the Labor Commissioner; the CPRs submitted to the

Labor Commissioner by the Contractor are complete and accurate for the period of time covered by the

Pay Application.

5. I have reviewed the Subcontractors’ CPRs submitted to the Labor Commissioner; the CPRs submitted to

the Labor Commissioner by the Subcontractors are complete and accurate for the period of time covered

by the Pay Application.

I declare under penalty of perjury under California law that the forgoing is true and correct.

I executed this Certification on the _____th day of __________________, 20____

(Day) (Month) (Year)

At ____________________________________________________________________________

(City and State)

By: ______________________________________Name:_______________________________

(Signature) (Typed or Printed)

Instructions To Contractors For Certified Payroll Submittal Affidavit Page 2