Certified Payroll - Alaska Department Of Labor & Workforce - 2004

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CERTIFIED PAYROLL
Alaska Department of Labor & Workforce
Development
Labor Standards & Safety Division
Wage & Hour Administration
Contractor Name
_____Contractor
_____SubContractor
Address
Phone
Week Ending
Dept. Labor Projet # Project Name and Location
Amount of Contract
Date Work Started
Est. Completion Date
Contractor License No.
Payroll No.
Contracting Agency Project #
Name, Permanent Domicile Address (NO P.O.
Date of the Month
Specific Work Class Code
DEDUCTIONS
BOX or RURAL ROUTES ACCEPTED) and
Including certificate #'s for
Union
Total
Gross
Apprentice
OTHER
Mailing Address (if different)
Electricians, Plumbers,
Hourly
Total
Net Amount
Check #
Membership?
Day of the Week
Hours
Amount
(%) if
(EXPLAIN)
Painters, Powderman,
If NONE put
Rate Paid
Deductions
Paid
Issued
FED W/H
UNION
Applicable
Worked
Earned
FICA
ESD
Garn or
N/A
TAX
DUES
Asbestos Workers. Truck
DO NOT include Social Security Numbers
S
M
T
W
TH
F
S
Medical
Drivers include truck
on this form
Insurance
license number
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Weekly Certified Payroll Form, Pg 1: Revised
6/2003

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