Public Works Payroll Reporting Form
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PUBLIC WORKS PAYROLL REPORTING FORM
California
Department of
Industrial Relations
Page ______ of ______
NAME OF CONTRACTOR:
CONTRACTOR'S LICENSE NO.:
ADDRESS:
OR SUBCONTRACTOR:
SPECIALITY LICENSE NO.:
PAYROLL NO.:
FOR WEEK ENDING:
SELF-INSURED CERTIFICATE NO.:
PROJECT OR CONTRACT NO.:
(4)
DAY
(5)
(6)
WORKERS' COMPENSATION POLICY NO.:
PROJECT AND LOCATION:
(9)
(1)
(2)
(3)
M
T
W
TH
F
S
S
(7)
(8)
HOURLY
DATE
NAME, ADDRESS AND
WORK
TOTAL
RATE
GROSS AMOUNT
NET WGS
CHECK
SOCIAL SECURITY NUMBER
CLASSIFICATION
HOURS
OF PAY
EARNED
DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS
PAID FOR
NO.
OF EMPLOYEE
WEEK
HOURS WORKED EACH DAY
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
SDI
PENSION
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
PROJECT
PROJECTS
S
TRAV/
TOTAL
TRAING.
FUND
DUES
SAVINGS
OTHER*
SUBS.
DEDUC-
ADMIN
TIONS
O
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
SDI
PENSION
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
PROJECT
PROJECTS
S
TRAV/
TOTAL
TRAING.
FUND
DUES
SAVINGS
OTHER*
SUBS.
DEDUC-
ADMIN
TIONS
O
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
SDI
PENSION
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
PROJECT
PROJECTS
S
TRAV/
TOTAL
TRAING.
FUND
DUES
SAVINGS
OTHER*
.
DEDUC-
SUBS
ADMIN
TIONS
O
THIS
ALL
FED.
FICA
STATE
VAC/
HEALTH
SDI
PENSION
TAX
(SOC. SEC.)
TAX
HOLIDAY
& WELF.
PROJECT
PROJECTS
S
TRAV/
TOTAL
TRAING.
FUND
DUES
SAVINGS
OTHER*
SUBS.
DEDUC-
ADMIN
TIONS
O
CERTIFICATION MUST be completed
Any other deductions, contributions and/or payments whether or not included or required by prevailing
S = STRAIGHT TIME
*OTHER –
wage determinations must be separately listed. Use extra sheet(s) if necessary
(See reverse side)
Form A-1-131 (New 2-80)
O = OVERTIME
SDI = STATE DISABILITY INSURANCE
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