Certified Payroll - Alaska Department Of Labor & Workforce Development
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1
2Contractor Name
_____ Contractor
_____Subcontractor
Address
CERTIFIED PAYROLL
Alaska Department of Labor &
Workforce Development
Phone
Contractor License Number
Week Ending:
Payroll No.
Contracting Agency Project
Labor Standards & Safety Division
Number
Wage & Hour Administration
Project Name and Location
Date Your
Your Est. Completion Date
Amount of Your Contract
Dept. of Labor Project
Work Started
#
1. Name of Employee
Specific Work Class
DAYS OF WORK WEEK
Code *
Including certificate
2. Permanent Domicile Address
numbers for electricians,
Net
Total
Hourly
Gross
Check #
Plumbers, Painters,
Total
(NO P.O. BOX or RURAL ROUTES ACCEPTED)
Amount
Powdermen, Asbestos
Hours
Rate Paid
Earnings
Issued
3. Mailing Address (if different from #2)
Deductions
Date of the Month
Workers. Truck drivers
Paid
include truck license number.
DO NOT include Social Security Numbers
Classification Code
ST
W
1. ______________________________________
E
OT
Employee Name
E
Classification
K
FB
2. ______________________________________
1
Date of the Month
________________________________________
Cert. of Fitness #
3.
Truck License # (if
W
ST
________________________________________
applicable)
E
E
________________________________________
Union
OT
K
________________________________________
Apprentice % (if
2
FB
applicable)
Classification Code
Date of the Month
1. ____________________________________
Employee Name
Classification
ST
W
E
E
OT
2. ____________________________________
K
Cert. of Fitness #
______________________________________
FB
1
Truck License # (if
Date of the Month
applicable)
3.
_____________________________________
W
E
ST
______________________________________
E
Union
K
______________________________________
OT
2
Apprentice % (
if
applicable)
FB
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Bi-weekly Form - 07-6058 - Revised April 2004
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