Form A-1-131 - Public Works Payroll Reporting Form (Fillible) - 2003 Page 2
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212ND WESTDIV 4295/1 (Rev. 5-03) (Back)
(4) The contractor, or subcontractor as appropriate, hereby states that:
DATE
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS,
I, ___________________________________________,
____________
FUNDS, OR PROGRAMS
(Name of signatory party)
(Title)
Do hereby state:
In addition to the basic hourly wage rates paid to each employee listed in
(1) That I pay or supervise the payment of the persons employed by
the above referenced payroll, payments to fringe benefits as listed
_________________________________________________________________
in the contract have been or will be made to appropriate programs
for the benefit of such employees, except as noted in Section 4
(Contractor or Subcontractor)
(c) below.
on the ___________________________________________________________
(Building or Work)
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
and that during the payroll period commencing on the _____ day of
________, 20____, and ending the _____ day of ________, 20____, all
Each employee listed in the above referenced payroll has been paid, as
persons employed on said project have been paid the full weekly wages
indicated on the payroll, an amount not less than the sum of the
earned, that no rebates have been or will be made either directly or
applicable basic hourly wage rate plus the amount of the required
indirectly to or on behalf of said
fringe benefits as listed in the contract, except as noted in
_________________________________________________________________
Section 4 (c) below.
(Contractor or Subcontractor)
from the full weekly wages earned by any person and that no deductions
(c) EXCEPTIONS
have been made either directly or indirectly from the full wages earned by
any person, other than permissable deductions as defined in regulations,
Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the
EXCEPTION (Craft)
EXPLANATION
Copeland Act, as amended (48 Stat. 948,63 Stat. 108, 72 Stat. 967; 76 Stat.
537; 40 U.S.C. 276c), and described below:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
(2) That any payrolls otherwise under this contract required to be submitted
for the above period are correct and complete; that the wage rates for
laborers or mechanics contained therein are not less than the applicable
wage rates contained in any wage determination incorporated into the
contract; that the classifications set forth therein for each laborer or
mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered
in a bona fide apprenticeship program registered with a State
REMARKS
apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized
agency exists in a State, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
NAME AND TITLE
SIGNATURE
The willful falsification of the above statements may subject the contractor or subcontractor to civil or
criminal prosecution. See Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code.
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