Form A-1-131 - Public Works Payroll Reporting Form (Fillible) - 2003

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DEPARTMENT
diR
PUBLIC WORKS PAYROLL REPORTING FORM
of INDUSTRIAL
RELATIONS
PAGE
OF
CONTRACTOR OR SUBCONTRACTOR NAME
CONTRACTORS
ADDRESS
LICENSE #
SPECIALTY
LICENSE #
PAYROLL NO.
SELF INSURED
PROJECT OR CONTRACT NO.
CERTIFICATE #
FOR WEEK ENDING
WORKERS COMPENSATION
PROJECT AND LOCATION
POLICY #
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
DAY
EMPLOYEE’S NAME, ADDRESS
AND SOCIAL SECURITY #
S M T W Th F S
DEDUCTIONS, CONTRIBUTIONS, AND PAYMENTS
GROSS
DATE
AMOUNT
EARNED ON
CHECK
PROJECT(S)
HOURS WORKED EACH DAY
NUMBER
FEDERAL
FICA
STATE
VACATION
HEALTH &
THIS
ALL
TAXES
(SOC SEC)
TAXES
SDI
HOLIDAY
WELFARE
PENSION
TRAINING
S
FUND
TRAVEL
TOTAL
NET PAID
ADMIN.
DUES
& SUBS
SAVINGS
MEDICARE
OTHER
DEDUCTS
FOR WEEK
O
$0.00
$0.00
FEDERAL
FICA
STATE
VACATION
HEALTH &
THIS
ALL
TAXES
(SOC SEC)
TAXES
SDI
HOLIDAY
WELFARE
PENSION
TRAINING
S
FUND
TRAVEL
TOTAL
NET PAID
ADMIN.
DUES
& SUBS
SAVINGS
MEDICARE
OTHER
DEDUCTS
FOR WEEK
O
$0.00
$0.00
FEDERAL
FICA
STATE
VACATION
HEALTH &
THIS
ALL
TAXES
(SOC SEC)
TAXES
SDI
HOLIDAY
WELFARE
PENSION
TRAINING
S
FUND
TRAVEL
TOTAL
NET PAID
ADMIN.
DUES
& SUBS
SAVINGS
MEDICARE
OTHER
DEDUCTS
FOR WEEK
O
$0.00
$0.00
S = Straight Time O = Overtime
* OTHER Any other deductions, contributions, and/or payments whether or not required by
CERTIFICATION must be completed (see back)
prevailing wage determinations must be separately listed. Use extra sheets if necessary.
Form A-1-131 (Rev 5/03) Please note that this form has been resized from 8.5 x 14 to 8.5 x 11 Get all of your construction related forms from

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