Massachusetts - Weekly Payroll Records Report & Statement Of Compliance Form Page 2
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2MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Company's Name:
Address:
Phone No.:
Payroll No.:
Employer's Signature:
Title:
Contract No:
Tax Payer ID No.
Work Week Ending:
Awarding Authority's Name:
Public Works Project Name:
Public Works Project Location:
Min. Wage Rate Sheet No.
General / Prime Contractor's Name:
Subcontractor's Name:
"Employer" Hourly Fringe Benefit Contributions
(B+C+D+E)
(A x F)
Project
Project Gross
Hours
Health &
Wages
Hours
Worked
(G)
Employee is
Appr.
(A)
Hourly Base
Welfare
ERISA
Supp.
Total Hourly
OSHA 10
Rate
Wage
Insurance
Pension Plan
Unemp.
Prev. Wage
Check No.
All Other
Total Gross
Employee Name & Complete Address
Certified (?)
Work Classification:
(%)
Su.
Mo.
Tu.
We.
Th.
Fr.
Sa.
(B)
(C')
(D)
(E)
(F)
(H)
Hours
Wages
NOTE:
Pursuant to MGL Ch. 149 s.27B, every contractor and subcontractor is required to submit a "true and accurate" copy of their weekly payroll records directly
to the awarding authority. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.
Date recieved by awarding authority
Page
of
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